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Digitized  by  the  Internet  Arciiive 

in  2007  with  funding  from 

IVIicrosoft  Corporation 


http://www.archive.org/details/contributiontosuOOthoriala 


A    CONTRIBUTION 


TO   THE 


SURGERY  OF  THE  SPINAL  CORD. 


A   CONTKIBUTION 


TO   THE 


SURGERY  OF  THE  SPINAL  CORD. 


BY. 


WILLIAM  THORBURN,  B.S.,  B.Sc,  M.D.  (Lokd.) 

FELLOW   OF  THE   ROYAL  COLLEGE  OF   SUEGEONS   OF   ENGLAND  ; 

SURGICAL    REGISTRAR    TO     THE    MANCHESTER    ROYAL    INFIRMARY; 

FORMERLY    SURGICAL     TUTOR    TO    THE    OWENS    COLLEGE,     MANCHEBTEB. 


imitb  DiagramSt  illustrations,  auD  tables. 


PHILADELPHIA: 
BLAKISTON,     SON    AND    CO. 

1012    WALNUT    STREET. 

144382 


3  1 1^-5  ^0^H3  SlU 


400 


INTKODUCTION. 


In  tlie   following   pages  will   be   found   recorded   a   number   of 

clinical   observations,  chiefly   upon  injuries  of   the   spinal   cord, 

and  certain  other  traumatic  affections,  formerly  supposed  to  be 

of  organic  and  spinal  origin,  but  now  generally  attributed  to  a 

totally  different  form  of  nervous  disturbance.      Although  many 

of   these   observations   have   been   already  published   in  various 

]       medical  journals,  yet  the  present  book  is  by  no  means  a  mere 

'i       reprint,   inasmuch  as   the   arrangement    adopted,  and   the   con- 

'       necting  links   of  thought   here   supplied,  not   only  render  the 

i      result  an  extension  of  previous  work,  but  give  to  it  a  coherence 

^  and  unity  which  was  not  attempted  in  the  original  papers.  It  is, 
however,  hardly  necessary  for  me  to  say  that  the  work  lays  no 

C  claim  to  be  a  systematic  treatise,  or  even  an  exhaustive  mono- 
graph, upon  the  above  important  subjects,  but  that  it  is  merely 
a  record  of  personal  observations  and  deductions. 

^  Two  considerations  have  chiefly  led  to  the  production  of  this 

book.  In  the  first  place,  it  must  be  generally  admitted  that, 
until  very  recent  years,  the  published  descriptions  of  the  symp- 
toms of  spinal  injuries  have,  except  in  the  hands  of  a  few 
such  observers  as  Ollivier  and  Mr.  Jonathan  Hutchinson,  been  so 
vague  and  indefinite,  as  to  be  almost  valueless  for  the  purpose  of 
throwing  light  upon  the  more  obscure  questions  of  spinal  patho- 
logy and  physiology,  or  even  of  permitting  an  accurate  diagnosis 
of  the  cases  themselves.  And  yet  we  have  in  such  injuries  a 
perfect  mine  of  wealth,  which,  properly  utilised,  can  hardly  fail 
to  advance  our  knowledge  of  the  normal  and  diseased  action  of 


VI  INTRODUCTION. 

this  portion  of  the  nervous  system :  and  there  cannot  be  a  doubt 
that  the  "experiments"  provided  for  us  by  traumatic  lesions 
of  the  spinal  cord  must,  in  their  turn,  illuminate  those  other 
branches  of  physiological  and  pathological  science  to  the  growth 
of  which  they  owe  the  attention  now  bestowed  upon  them. 

The  second  consideration  to  which  I  refer  is  that,  acting 
under  strict  antiseptic  precautions  and  aided  by  modem  know- 
ledge, surgeons  will  probably,  in  the  near  future,  open  the 
spinal  canal  with  as  little  danger  and  as  little  hesitation  as  they 
now  operate  upon  the  cavity  of  the  cranium ;  but  that  in  order  to 
permit  of  such  an  extension  of  therapeutic  art  it  will  be  necessary 
still  further  to  increase  the  accuracy  of  our  diagnostic  methods. 

On  these  grounds,  then,  I  feel  that  no  contribution,  however 
slight,  which  may  aid  in  the  elucidation  of  the  points  referred 
to,  ought  to  be  withheld  from  the  medical  public,  and  the  only 
question  with  me  is  whether  the  importance  of  the  following 
observations  is  sufficient  to  justify  their  collection  in  the  present 
form.  Whether  this  is  so  or  not  must  now  be  left  to  the  judg- 
ment of  the  reader ;  but,  whatever  this  judgment  may  be,  at  least 
I  cannot  plead  that  my  opportunities  for  undertaking  the  work 
have  not  been  ample.  Having  entered  upon  my  medical  educa- 
tion just  at  the  time  when  the  diseases  of  the  nervous  system 
began  to  be  studied  in  Manchester,  with  an  enthusiasm  which 
has  made  itself  widely  felt,  I  have  from  the  first  been  thrown 
under  the  influence  of  teachers  and  friends  for  whose  assistance 
and  advice  I  cannot  suflSciently  express  my  gratitude ;  and 
further,  during  the  last  four  years  my  position  as  Surgical 
Registrar  to  the  Manchester  Royal  Infirmary  has  given  me  access 
to  an  almost  unrivalled  field  for  clinical  observation,  in  which  I 
have  had  the  singular  good  fortune  to  work  under  a  stafiF,  who 
have  not  only  afforded  me  every  opportunity  for  observing  their 
cases,  but  have  also  given  me  permission  to  publish  them  as  freely 
as  if  they  were  my  own.  To  the  large-minded  generosity  of 
these  gentlemen — the  Physicians  and  Surgeons  of  the  Manchester 
Infirmary — I  am  unable  adequately  to  express  my  obligation. 

If,  where  I  have  received  so  much  and  such  general  kindness 
and  assistance,  any  selection  be  permissible,  I  would  tender  my 


INTRODUCTION.  VU 

especial  thanks  to  Dr.  David  Little,  whose  ready  assistance  in 
controlling  my  observations  upon  morbid  conditions  of  the 
optic  discs  endows  them  with  the  stamp  of  his  high  authority. 
But  above  all,  I  am  indebted  to  two  gentlemen,  whose  constant 
assistance  and  advice  have  been  of  an  absolutely  inestimable 
value  to  me — my  former  teacher,  Dr.  James  Ross,  to  whose 
inspiration  must  be  attributed  whatever  is  of  value  in  this  book, 
and  my  colleague,  Mr.  Alexander  Wilson,  who  has  ungrudgingly 
lent  me  his  aid  in  the  preparation  of  the  work  for  the  press. 

W.  T. 


THE 

SUEGERY  OF  THE   SPINAL  CORD. 


CHAPTER  I. 

INJURIES  TO  THE  CERVICAL  REGION  OP  THE 
SPINAL  CORD. 

Since  January  1885  there  have  been  admitted  to  the  Manchester 
Infirmary  twenty-one  cases  of  injury  to  the  cervical  region  of  the 
spinal  cord,  from  an  examination  of  which  I  have  been  able  to 
arrive  at  certain  conclusions  as  to  the  exact  distribution  of  the 
motor  and  sensory  functions  of  the  brachial  enlargement.  As  none 
of  the  injuries  occurred  higher  than  the  origin  of  the  fourth  pair  of 
cervical  nerves,  I  have  nothing  to  add  to  our  previous  knowledge 
of  the  functions  of  the  upper  portion  of  the  cord,  but  shall  proceed 
at  once  to  the  consideration  of  that  section  comprised  between 
the  third  cervical  and  second  dorsal  roots.  Before  doing  so,  it 
will,  however,  be  convenient  to  summarise  the  results,  as  regards 
localisation,  obtained  by  previous  observers :  results  derived  from 
evidence  of  three  classes — experimental,  clinical,  and  anatomical. 

Drs.  Ferrier  and  Yeo^  have  investigated,  in  the  monkey,  the 
effects  of  irritation  of  each  of  the  cervical  roots,  and,  on  the  basis 
of  these  researches,  Ferrier  ^  has  assigned  certain  muscles  to  each 
root,  which,  inverting  the  original  arrangement,  we  find  to  be  as 
follows,  from  above  downwards  : — 

Fourth  cervical  type: — Deltoid,  rhomboid,  supra-  and  infra- 
spinatus (teres  minor),  biceps,  brachialis  anticus,  supinator 
longus,  extensors  of  wrist  and  fingers,  diaphragm. 

Fifth  cervical  type : — Deltoid  (clavicular  portion),  biceps, 
brachialis  anticus,  serratus  magnus,  supinator  longus,  extensors 
of  wrist  and  fingers. 

^  Proc.  Roy.  Soc,  No.  ccxii.  p.  12.  ^  Brain,  vol.  iv.,  1882,  p.  226. 

A 


SDEGERY    OF   THE    SPINAL   COED. 


Sixth  cervical  type : — Latissimus  dorsi,  pectoralis  major,  serratus 
magnus,  pronators  (flexor  of  wrist  ?),  triceps. 

Seventh  cervical  type  : — Teres  major,  latissimus  dorsi,  suhscapu- 
laris,  pectoralis  major,  flexors  of  wrist  and  fingers  (median),  triceps. 

Eighth  cervical  type : — Long  flexors,  ulnar  flexors  of  wrist, 
intrinsic  muscles  of  hand,  extensors  of  wrist  and  phalanges,  long 
head  of  triceps  (pectoralis  major  ?). 

First  dorsal  type: — The  intrinsic  muscles  of  the  hand,  viz., 
muscles  of  the  thenar  and  hypothenar  eminences  and  interossei. 

Two  objections  may  be  taken  to  this  classification :  ( i .)  that 
it  is  diflScult,  if  not  impossible,  in  irritating  certain  nerve-roots,  to 
be  certain  that  the  irritation  has  not  spread  to  adjacent  fibres  ;  and 
(2.)  that  the  conclusions  may  be  inapplicable  to  man,  in  view  of 
the  fact  that  in  him  the  motor  functions  are  more  specialised  and 
less  associated,  and  that  the  spinal  nuclei  may,  therefore,  be  more 
concentrated,  so  that  the  entire  nerve-supply  for  a  given  muscle 
may  originate  in  a  smaller  area,  and  may  be  distributed  by  a 
smaller  number  of  roots.  It  is  certainly  obvious  that,  whether  it 
be  due  to  one  of  these  reasons  or  not,  we  do,  as  a  matter  of  fact, 
find  much  overlapping  in  the  series  of  muscles  assigned  to  each  of 
Terrier's  root-types. 

It  has,  however,  been  ascertained  that  clinical  observation  coin- 
cides closely  with  the  results  thus  obtained,  and  that  in  cases  of 
polio-myelitis  and  root-paralyses  the  affected  muscles  form  very 
similar  groups.  Cases  capable  of  demonstrating  such  points  are 
comparatively  infrequent,  and  the  subject  has  thus  had  to  be 
worked  out,  not  by  one,  but  by  several  observers,  but  the  follow- 
ing summary  given  by  Dr.  Gowers^  represents  the  general 
conclusions : — 


Motor. 


Roots. 


Motor. 


Upper    part  J 
of  trapezius  ( 


Lower    neck 
muscles 


Middle    part 
of  trapezius 


Fourth  cervical 
Fifth  cervical 

Sixth  cervical 

Seventh  cervical 


Eighth  cervical 
First  dorsal 


Shoulder 
muscles 


Diaphragm 

Serratus 
Flexors  of  elbow 
Supinators 

Extensors    of     wrist    and 
fingers 


Sensory. 


Extensors  of  elbow 
Flexors      of      wrist 

fingers 
Pronators 

Muscles  of  hand 


and 


Shoulder 


Arm 


Hand  (ulnar 
n.  lowest) 


^  Diseases  of  the  Nervous  System,  vol  i.  p.  142. 


INJURIES    TO    THE    CERVICAL    REGION.  3 

Herringham/  examining  their  relations  from  a  purely  anatomi- 
cal point  of  view,  has  in  the  human  subject  carefully  dissected 
the  cervical  nerve-roots  through  the  brachial  plexus,  and  has 
obtained  the  following  results  as  to  their  distribution : — 

Fifth  cervical  root: — Biceps,  brachialis  anticus,  subscapularis, 
deltoid. 

Sixth  cervical  root : — Pectoralis  major,  biceps,  brachialis 
anticus,  pronator  teres,  flexor  carpi  radialis,  superficial  thenar 
muscles,  subscapularis,  teres  major,  deltoid,  supinator  longus  et 
brevis,  extensor  carpi  radialis  longior  et  brevior. 

Seventh  cervical  root: — Pectoralis  major  et  minor,  coraco- 
brachialis,  flexor  sublimis,  latissimus  dorsi,  triceps,  extensor 
carpi  radialis  longior  et  brevior. 

Eighth  cervical  root : — Pectoralis  major  et  minor,  flexor  sub- 
limis, latissimus  dorsi,  triceps. 

First  dorsal  root : — Pectoralis  major  et  minor. 

This  anatomical  method  of  investigation  would  appear  to  be 
less  open  to  objection  than  any  other,  and  the  general  conclusions 
will  be  found  to  accord  fairly  well  with  those  previously  obtained  ; 
the  most  important  difference  being  that  the  intrinsic  muscles  of 
the  hand  are  assigned  a  higher  level  of  origin  than  in  the  experi- 
mental and  clinical  observations.  The  result  is,  however,  not  a 
perfect  clinical  guide,  inasmuch  as  the  connections  are  too  minute, 
branches  evidently  being  traced  into  muscles  for  which  they  do 
not  contribute  any  important  path  of  voluntary  impulses,  and  the 
paralysis  or  irritation  of  which  will,  therefore,  not  be  productive 
of  any  symptoms. 

An  accurate  knowledge  of  these  localisations  being  of  the 
greatest  importance  to  the  surgeon  who  would  operate  for  the 
relief  of  pressure  lesions  of  the  spinal  cord,  I  have  endeavoured 
to  work  out  an  independent  scheme  by  observing  in  detail  the 
extent  of  the  paralysis  and  anaesthesia  in  cases  of  injury,  both 
at  an  early  period,  and  also  during  the  progressive  ascending 
myelitis  which  usually  ensues.  The  extent  of  the  paralysis  has 
been  deduced  partly  from  the  obvious  loss  of  voluntary  control 
over  the  muscles,  partly  from  the  positions  assumed  by  the 
limbs,  and  partly  from  the  electric  reactions.  The  exact  site  of 
the  lesion  has  generally  been  subsequently  confirmed  by  post- 
mortem examination. 

Following  out  this  method,  I  have  been  led  to  arrange  the 

^  Proc.  Roy.  Soc,  No.  ccxliii.,  18S6,  p.  255. 


4  SURGERY    OF   THE   SPINAL    CORD. 

various  spinal  muscular  nuclei  in  the  following  order,  from  above 
downwards,  assigning  each  to  the  nerve-root  by  which  its  efferent 
fibres  probably  leave  the  cord  : — 


Supraspinatus  and  infraspinatus 

Teres  minor  (?) 
I  Biceps 
(  Braehialis  anticus  ^ 

Deltoid    . 
(  Supinator  longus 
I  Supinator  brevis  (?) 

Subscapularis 

Pronators 

Teres  major     . 

Latissimus  dorsi 

Pectoralis  major 
(  Triceps    . 
I  Serratus  magnus 

Extensors  of  the  wrist 

Flexors  of  the  wrist 

Interossei 

Other  intrinsic  muscles  of  the  hand 


Fourth  cervical  nerve. 


-Fifth  cen-ical  nerve. 


y  Sixth  cervical  nerve. 


Seventh  cervical  nerve. 
Eighth  cervical  nerve. 

First  dorsal  nerve. 


In  endeavouring  to  elucidate  this  matter,  I  have  entirely 
ignored  the  results  arrived  at  by  other  methods,  and  have  con- 
fined myself  entirely  to  the  evidence  yielded  by  the  cases  referred 
to,  the  more  so  as  the  conclusions  are  consistent  with  the  majority 
of  previous  observations. 

It  will  be  obvious  that  the  method  adopted,  relying,  as  it  does, 
principally  upon  the  position  and  mobility  of  the  limbs,  indicates 
only  the  chief  point  of  origin  of  the  motor  nerve-fibres  for  each 
muscle,  and  that  where  muscles  are  supplied  from  more  than  one 
level  or  root,  the  minor  connections  are  disregarded.  Thus,  in  the 
'  case  of  the  pectoralis  major,  there  is  no  doubt  that  several  roots 
supply  the  muscle,  but  of  these  one  only  could  be  identified.  The 
conclusions,  however,  although  probably  thus  wanting  in  minute 
accuracy,  will  obviously  be  of  the  more  value  as  clinical  data, 
and  are  not  open  to  the  objections  presented  by  Herringham's 
more  complete  scheme.  Time  alone  will  explain  the  minor  dis- 
crepancies between  my  arrangement  and  those  of  others. 

While  narrating  the  following  cases  in  the  order  best  suited  to 
illustrate  the  above  table,  I  shall  refer  from  time  to  time  to  other 
points  of  interest  which  they  present. 

^  I  have  not  identified  the  braehialis  anticus,  but,  from  well-known  clinical  facts, 
assume  it  to  be  in  close  connection  with  the  biceps. 


INJURIES   TO    THE   CERVICAL   REGION.  $ 

Case  i. — Fracture-dislocation  hetiveen  the  fourth  and  fifth  cervical 
vertebrce — Complete  paralysis  of  limbs  and  trunk — Death. 

The  following  case  was  under  the  care  of  Mr.  Heath.  The 
notes  were  taken  by  the  dresser,  Mr.  W.  H.  Iddon. 

M.  L.,  male,  aged  forty-five,  was  admitted  to  the  Manchester 
Infirmary  on  March  27,  1886.  He  had  fallen  from  a  scaffolding 
some  forty  feet  in  height.  In  addition  to  three  lacerated  scalp- 
wounds,  he  presented  the  following  symptoms.  There  was  severe 
pain  in  the  back  of  the  neck.  All  four  extremities  were  "  com- 
pletely paralysed,"  as  were  the  muscles  of  the  trunk  and  abdomen. 
The  limbs  and  trunk  were  absolutely  anaesthetic  below  a  line 
running  across  the  thorax  at  the  level  of  the  second  intercostal 
space,  and  thence  across  the  deltoids  at  the  junction  of  their 
upper  and  middle  thirds ;  above  this  line  sensation  was  normal, 
the  transition  being  quite  abrupt.  The  pupils  were  equal,  and 
were  thought  to  be  of  normal  size.  There  was  no  mental  affection. 
Respiration  was  diaphragmatic ;  the  urine  was  retained ;  priapism 
was  constant.  Death  took  place  a  few  hours  after  admission, 
apparently  from  dyspnoea. 

The  temperature  was  taken  several  times,  but  was  unfortunately 
not  recorded.  The  house-surgeon  assures  me  that  it  was  certainly 
not,  at  any  time,  far  from  the  normal. 

At  the  post-mortem  examination  there  was  found  a  fracture 
through  the  body  of  the  fifth  cervical  vertebra  and  the  inter- 
vertebral disc  immediately  above  it.  The  spines  of  the  third, 
fourth,  and  fifth  vertebrae  were  broken  off.  Around  the  dura 
mater  at  this  point  was  a  very  slight  effusion  of  blood.  The 
cord  was  much  lacerated,  being  almost  torn  across  opposite  the 
seat  of  fracture,  and  was  very  soft  for  a  distance  of  nearly  i^ 
in.,  being  reddened  by  extravasated  blood.  The  skull  and  its 
contents  were  uninjured.      The  lungs  were  oedematous. 

Here  we  have  a  lesion  affecting  the  junction  of  the  fourth  and 
fifth  cervical  vertebrae,  so  that  the  fifth  root,  which  escapes  from 
the  spinal  canal  above  the  fifth  vertebra,  would  be  injured  together 
with  the  cord  itself  below  this  point.  Hence  we  get  complete 
paralysis  of  sensation  and  motion  in  the  upper  extremity,  the 
whole  of  the  brachial  plexus  being  cut  off  from  the  brain,  with 
the  exception  of  its  branch  from  the  fourth  cervical  nerve.  The 
present  case  unfortunately  yields  no  evidence  as  to  the  distribu- 
tion of  this  branch,  the  condition  of  the  posterior  scapular  muscles 
not  having  been  specially  noted. 


SURGERY  OF    THE    SPINAL    CORD. 


Case  2. — Dislocation  between  the  fourth  and  fifth  cervical  vertebrce 
— Complete  paralysis  of  limbs  and  trunk — Death. 

C.  D.  was  admitted  under  the  care  of  Mr.  Hardie,  the  notes 
being  taken  by  Mr.  Benson,  house-surgeon.  The  patient,  a 
carter,  thirty-nine  years  of  age,  was  admitted  on  August  3, 
1886,  having  fallen  from  a  van,  of  which  the  wheels  had  passed 
over  his  shoulders. 

On  admission  he  complained  of  great  pain  at  the  back  of  the 
neck.  All  four  limbs  were  completely  paralysed,  and  there  was 
anaesthesia  below  the  level  of  the  descending  branches  of  the 
cervical  plexus.  Respiration  was  diaphragmatic.  The  fseces  were 
passed  unconsciously.  Both  pupils  were  contracted,  the  palpebral 
fissures  narrowed,  and  the  eyeballs  presented  a  remarkable  sensa- 
tion of  softness  owing  to  paralysis  of  the  posterior  orbital  muscles. 
The  pulse  was  full,  of  low  tension,  and  beating  at  the  rate  of 
60  per  minute.  The  temperature  on  the  evening  of  admission 
was  96.8°. 

He  passed  a  restless  night,  and  on  the  next  morning  the 
following  additional  symptoms  were  noted.  There  was  constant 
priapism.  The  urine  was  retained,  and  upon  being  withdrawn  by 
the  catheter,  was  examined  for  sugar  and  albumin,  with  negative 
results.  The  face  was  much  congested ;  the  pulse  remained  full 
and  soft,  beating  at  the  rate  of  130  per  minute.  The  tempera- 
ture at  8  A.M.  was  102.2°.  When  the  patient  was  told  to  take 
a  deep  breath,  he  contracted  the  levator  anguli  scapulae  muscles, 
which  could  be  distinctly  felt  beneath  the  trapezius,  thus  indicating 
an  attempt  to  fix  the  scapula,  and  bring  into  pluy  the  extraordinary 
muscles  of  inspiration. 

At  10  A.M.  the  patient's  temperature  had  risen  to  103.6° ;  at 
midday  to  105°;  at  2  P.M.  to  106°.  At  4  p.m.  it  was  107.8°. 
He  now  became  insensible  and  livid,  and  the  breathing  was  more 
shallow,  the  whole  body  being  covered  with  a  profuse  hot  sweat. 
At  5  P.M.  he  died,  the  temperature  having  risen  to  108°.  The 
temperature  after  death  was  not  recorded. 

At  the  post-mortem  examination  there  was  found  a  rupture  of 
the  cartilage  between  the  bodies  of  the  fourth  and  fifth  cervical 
vertebrae,  these  two  bodies  being  so  widely  separated  behind  that 
a  finger  could  be  introduced  between  them.  They  thus  formed 
an  obtuse  angle  posteriorly,  pressing  on  the  contents  of  the  spinal 
canal.  At  this  point  there  was  marked  post-mortem  staining  of 
the  meninges,  but  decomposition  was  so  far  advanced  that  it  could 


INJURIES    TO    THE    CERVICAL   REGION.  7 

not  be  ascertained  whether  they  were  inflamed.  The  cord  itself 
was  here  compressed,  through  a  vertical  extent  of  three-quarters 
of  an  inch,  into  a  narrow  band,  and  was  very  much  softened,  there 
being  no  distinction  between  the  grey  and  the  white  matter. 
Elsewhere  the  cord  showed  only  post-mortem  softening. 

The  posterior  parts  of  both  lungs  were  much  congested,  and 
in  the  brain  were  numerous  puncta  cruenta.  There  were  no 
other  changes  of  interest. 

This  case  is  similar  to  the  last,  the  lesion  again  involving  the 
roots  of  the  fifth  cervical  nerves  and  all  parts  below  them,  and  the 
symptoms  being  the  same.  Both  cases  are  of  value  mainly  as 
contrasting  with  those  which  follow. 


Case  3. — Fi'acture-dislocation  between  the  fifth  and  sixth  cervical 
vertebrce — Complete  paralysis  of  all  nerves  below  the  fifth  cer- 
vical— Death. 

L.  F.  was  admitted  to  the  Manchester  Royal  Infirmary  under 
the  care  of  Mr.  Jones  on  June  5,  1886.  The  patient  was  a 
man,  aged  sixty-eight,  a  labourer  by  occupation.  On  June  I, 
four  days  before  admission,  he  was  standing  on  a  short  ladder 
whitewashing,  when,  two  of  the  rungs  of  the  ladder  giving  way, 
he  fell  backwards  in  such  a  position  that  while  his  feet  remained 
caught  in  the  ladder,  he  first  struck  the  back  of  his  neck  against 
a  bench  some  2^  feet  above  the  ground,  and  then  fell  head  first 
to  the  ground.  At  the  same  time  he  thinks  that  his  bucket  of 
whitewash  fell  upon  him. 

He  at  once  became  unconscious,  remaining  so  for  several  hours. 
On  regaining  consciousness,  he  found  that  his  legs  were  quite 
immovable  and  his  arms  partially  so,  while  there  was  loss  of 
sensation  in  the  lower  portion  of  the  body,  coupled  with  a  dull 
aching  pain.  There  was  also  great  pain  in  the  head,  neck,  and 
shoulders.  The  urine  had  to  be  drawn  off  twice  daily.  He 
remained  in  this  condition  until  his  admission  to  the  Infirmary 
on  the  fourth  day  after  the  accident. 

When  admitted,  he  was  found  to  present  complete  paralysis  of 
the  lower  limbs  and  of  the  abdominal  and  thoracic  muscles.  All 
the  muscles  of  the  arms  were  paralysed,  with  the  exception  of  the 
biceps,  brachialis  anticus,  supinator  longus,  and  deltoid ;  the  con- 
sequence being  that  the  elbows  were  flexed,  the  shoulders  abducted 
and  rotated    outwards,  and    the   hands    and    arms   fell   into   the 


8 


SURGERY    OF   THE   SPINAL    CORD. 


position  indicated  in  the  annexed  engraving  (fig.  i),  taken  from 
a  photograph.  There  was  no  power  of  extension  of  the  forearm, 
but  a  fair  degree  of  power  of  flexion.  Some  external  rotation 
of  the  humerus  could  be  effected  by  the  supra-  and  infra- 
spinati.  The  pectoralis  major  and  latissimus  dorsi  were  paralysed. 
The  lower  limbs  and  trunk  were  completely  anaesthetic  as  high  as 
the  level  of  the  second  rib  in  front — i.e.,  as  high  as  the  descend- 
ing branches  of  the  cervical  plexus — and  apparently  to  the  third 
dorsal  vertebra  (?)  behind.  Above  this  point  sensation  was  nor- 
mal. The  upper  extremities  were  anaesthetic,  with  the  excep- 
tion of  the  radial  side  of  the  forearm  and  hand  and  the  balls 
of  the  thumbs.  All  the  cutaneous  reflexes  and  tendon  reactions 
were  absent  throughout.     Breathing  was  entirely  diaphragmatic. 


Fio.  I. — Position  occupied  by  the  limbs  in  a  case  of  complete  transverse  destruction  of  the  spinal 
cord  immediately  below  the  level  of  origin  of  the  fifth  cervical  nerves. 

The  urine  was  retained,  and  the  bowels  had  not  been  moved 
since  the  accident.  The  penis  was  subject  to  frequent  erec- 
tions with  seminal  emissions ;  on  the  back  were  several  bed- 
sores. The  pulse  was  slow  and  full ;  the  temperature  98°.  The 
pupils  were  both  somewhat  contracted.  Over  the  fifth  and  sixth 
cervical  vertebras  was  a  slight  prominence,  which  was  very  tender 
on  pressure.  The  only  treatment  adopted  was  complete  rest  on 
a  water-bed,  catheterisation  at  intervals,  and  some  simple  dressing 
for  the  bed-sores. 

During  the  progress  of  the  case  there  were  not  many  very 
important  deviations  from  the  symptoms  above  described.  The 
urine,  which  was  at  first  healthy,  became  turbid  and  alkaline  a  few 
days  after  admission.  After  this  the  bladder  was  washed  out  daily 
with  boracic  acid  lotion.     Priapism  became  more  constant.     The 


INJURIES   TO   THE    CEPwVICAL    EEGION.  9 

bowels  were  never  moved  except  after  the  use  of  an  enema  or  of 
croton-oil.  On  June  9,  four  days  after  admission,  the  arms  had 
become  completely  anaesthetic,  and  they  thereafter  remained  so. 
The  temperature  was  generally  slightly  below  the  normal ;  the 
pulse  was  often  50,  never  above  60.  Respiration  was  rapid 
throughout,  being  usually  about  20,  sometimes  30  per  minute. 

The  patient's  strength  failed  steadily,  and  at  times  there  was 
confusion  of  thought,  with  low  muttering  delirium  at  night.  He 
complained  mainly  of  pain  in  the  neck  and  of  cold  feet. 

On  June  i  5  he  had  lost  all  power  of  rotating  the  humerus  on 
both  sides,  any  passive  movement  of  the  shoulder-joints  being  very 
painful.  The  cheeks  fell  in  and  out  very  markedly  on  respira- 
tion. Although  the  power  of  the  voice  remained  good,  speech 
was  almost  unintelligible;  he  could  not  protrude  the  tongue 
beyond  the  teeth,  nor  freely  open  the  mouth.  There  was  marked 
fibrillar  trembling  of  the  masseters,  and  much  accumulation  of 
tenacious  saliva  about  the  mouth.  Bed-sores  had  formed  over  the 
sacrum,  on  the  inner  side  of  the  right  thigh,  and  on  the  inner  side 
of  the  left  knee,  these  having  hardly  changed  since  admission. 

On  June  17  the  contraction  of  the  deltoid  muscles,  which  had 
maintained  the  abducted  position  of  the  arms,  ceased,  and  the 
elbows  fell  to  the  sides,  the  elbow-joints  themselves  remaining 
flexed. 

From  this  date  the  patient  gradually  sank,  respiration  becoming 
more  laboured,  and  the  countenance  dusky,  while  there  was  in- 
creased apathy.  On  June  25  the  pupils  were  noted  as  being 
dilated  and  unequal,  the  right  being  the  larger ;  there  was  a 
commencing  "  bed-sore  "  on  the  chest ;  on  washing  out  the  bladder 
there  came  away  shreds  of  what  was  thought  to  be  mucous  mem- 
brane.     On  June  26  he  died  exhausted. 

At  the  post-mortem  examination  the  disc  between  the  fifth  and 
sixth  vertebrae  was  found  to  be  broken  across,  the  lower  part  of 
the  body  of  the  fifth  vertebra  being  tilted  forwards.  The  laminae 
were  uninjured,  but  the  right  superior  articular  process  of  the  fifth 
vertebra,  and  the  corresponding  transverse  process  of  the  sixth 
were  broken  off.  At  this  point  the  cord  was  compressed,  being 
flattened  for  a  distance  of  about  a  quarter  of  an  inch.  The  dura 
mater  was  here  yellowish  and  opaque,  the  arachnoid  and  pia 
mater  healthy.  The  cord  was  much  softened  for  a  distance  of 
two  or  three  inches  above  and  one  inch  below  the  seat  of  injury, 
especially  around  the  central  canal,  where  it  was  quite  diffluent 
and  of  a  yellowish  colour,  showing  under  the  microscope  numerous 
granule-cells.     The  rest  of  the  cord  was  healthy.     The  bladder 


lO  SURGERY    OF   THE    SPINAL    CORD. 

contained  a  quantity  of  blood-stained  turbid  fluid,  its  mucous 
membrane  hanging  in  shreds,  beneath  which  the  wall  was  dark 
and  livid  ;  inflammation  had  extended  to  the  pelvic  cellular  tissue 
and  the  peritoneum.  The  kidneys  were  congested,  and  presented 
numerous  scattered  points  of  suppuration  ;  there  was  no  dilation 
of  nor  suppuration  in  their  pelves.  The  other  organs  presented 
nothing  of  interest. 

This  case  is  a  sufficiently  typical  example  of  injury  to  the  spinal 
cord  above  the  origin  of  the  sixth  cervical  nerves.  Thus  we  find 
that,  with  the  exception  of  the  biceps,  brachialis  anticus  (?),  and 
supinators,  there  was  absolute  paralysis  of  the  intrinsic  muscles 
of  the  upper  extremity.  Of  the  extrinsic  muscles  of  the  upper 
limb,  the  only  ones  not  paralysed  were  the  deltoid  and  the 
external  rotators  of  the  humerus — the  teres  minor  and  spinati. 
The  case  is  thus  an  exact  counterpart  of  the  so-called  Erb's  para- 
lysis, in  which  we  meet  with  paralysis  of  the  same  muscles  which 
were  here  spared  ;  and  it  enables  us  to  confirm  previous  researches 
as  to  the  distribution  of  the  fifth  cervical  nerve-root.  From  the 
unopposed  action  of  the  above-mentioned  muscles  there  resulted 
the  characteristic  position  represented  in  the  figure,  but  how  far 
this  contraction  was  due  to  mere  tonics,  and  how  far  to  pathological 
spasm,  it  is  impossible  to  say. 

The  characteristic  position  of  the  limbs  observed  in  this  case 
has  been  previously  noted,  but  its  import  has  not,  I  believe,  been 
hitherto  fully  explained.  Thus,  in  the  London  Hospital  Reports 
for  1866,  Mr.  Jonathan  Hutchinson  mentions  a  case  in  which  a 
man  had  partial  paralysis  of  the  right  arm,  but  could  raise  the 
limb,  although  he  could  not  grasp ;  and  the  position  is  still  more 
clearly  indicated  in  another  case,  recorded  in  the  same  paper,  of 
a  crush  opposite  the  fifth  cervical  vertebra,  in  which  the  arms 
were  raised  to  a  level  with  the  shoulders,  and  the  forearms  flexed 
by  the  biceps. 

Again,  in  the  St.  Thomas's  Hospital  Reports  for  1870,  Mr. 
Churchill  describes  a  case  of  fracture  of  the  fifth  cervical  arch, 
with  crushing  of  the  cord,  in  which  the  patient  could  move  the 
shoulders  and  upper  arms  only.  In  the  latter  paper  is  also 
described  a  case  of  dislocation  forwards  of  the  sixth  cervical  ver- 
tebra, in  which  there  was  impaired  movement  of  the  arms,  attri- 
buted to  a  desire  to  keep  the  spine  immovable  :  the  upper  arms 
are  described  as  being  raised  to  a  right  angle  with  the  body, 
and  "  the  forearms  were  flexed  so  as  to  relax  the  muscles  and  to 
support  the  head ; "  the  same  case  apparently  presented  hyper- 


INJURIES    TO    THE   CERVICAL   REGION.  I  I 

sesthesia  of  the  radial  side  of  the  upper  limbs.  Clearly,  then, 
this  was  an  example  of  irritation  of  the  region  of  origin  of  the 
fifth  roots,  with  paralysis  below  that  level. 

Besides  illustrating  the  functions  and  distribution  of  the  fifth 
cervical  root,  our  case  suggests  that  the  deltoid  nuclei  are  situated 
below  those  for  the  biceps,  the  former  having  first  yielded  to  the 
ascending  myelitis.  This  suggestion  will  be  found  to  be  confirmed 
by  other  cases  mentioned  below. 

As  regards  sensation,  we  find  that  a  cord  lesion  which  cuts  off 
the  origin  of  all  the  nerves  of  the  brachial  plexus  below  the  fifth 
cervical  causes  anaesthesia  of  the  entire  upper  limb,  except  the 
outer  side  of  the  arm  and  forearm,  and  the  radial  border  of  the 
thumb,  i.e.,  a  part  of  the  region  supplied  by  branches  of  the 
musculo-spiral  nerve. 

The  affection  of  speech  and  other  symptoms  noted  in  the  pro- 
gress of  the  above  case  at  first  gave  rise  to  the  supposition  that 
there  might  be  some  extension  of  myelitis  to  the  medulla  oblon- 
gata ;  but  as  no  further  symptoms  of  bulbar  paralysis  developed 
themselves,  and  as  the  intermediate  cervical  muscles  were  un- 
affected, these  phenomena  would  appear  to  have  been  due  to  the 
general  debility  only. 


Case  4. — Fracture-dislocation  between  the  fourth  and  fifth  cervical 
vertebrae — Partial  paralysis  of  right  upper  limb — Total  para- 
lysis of  other  limbs  and  trunk — Death. 

T.  L.  was  admitted  under  the  care  of  Mr.  Heath  on  September 
7,  1886.  He  was  thirty-six  years  of  age,  and  a  carter  by  occu- 
pation. While  attending  to  his  horse  the  animal  had  fallen 
against  him,  crushing  him  against  the  manger,  the  corner  of 
which  struck  his  back  between  the  shoulders.  He  immediately 
fell  down  paralysed. 

On  admission,  there  was  found  no  external  bruise  or  other 
evidence  of  injury,  except  a  sense  of  soreness  and  stiffness  in  the 
lower  cervical  spine  ;  no  irregularity  of  the  spinous  processes  could 
be  detected.  The  lower  limbs  and  trunk  muscles  were  entirely 
paralysed,  as  was  also  the  left  upper  extremity ;  the  right  upper 
extremity  was  paralysed,  with  the  exception  of  the  deltoid  and 
biceps  (the  condition  of  the  brachialis  anticus  and  supinator  longus 
is  not  noted).  The  bladder  and  sphincter  ani  were  also  paralysed, 
and  there  was  priapism. 

There  was  anaesthesia  of  the  lower  limbs  and  trunk,  and  of  the 
upper  limbs  with  the  exception  of  the  radial  side  of  the  hand,  fore- 


12  SURGERY    OF   THE    SPINAL   CORD. 

arm,  and  arm  on  both  sides.  Breathing  was  entirely  diaphrag- 
matic. The  pupils  were  widely  dilated.  The  temperature  was 
1 00.6°.  The  treatment  consisted  in  the  use  of  a  water-bed  with 
ice-tubes  to  the  spine,  doses  of  ext.  ergot,  liq.  three  times  daily, 
and  catheterisation. 

'  At  8  A.M.  on  the  following  day  the  temperature  had  risen  to 
105.2°;  at  noon  it  was  104°;  and  then  again  gradually  rose, 
reaching  105.6°  before  death,  which  occurred  on  the  second  day. 
Breathing  became  more  difficult,  with  accumulation  of  mucus 
in  the  bronchial  tubes,  and  the  face  grew  very  livid.  The  man 
died  asphyxiated  about  thirty-six  hours  after  admission,  the  heart 
continuing  to  beat  for  some  ten  minutes  after  respiration  had 
stopped. 

At  the  post-mortem  examination  there  was  found  a  rupture  of 
the  cartilage  between  the  fourth  and  fifth  cervical  vertebrae,  "  which 
fracture  had  extended  across  posteriorly,  involving  the  laminae  of 
the  fourth  or  fifth  vertebrae,"  but  was  unaccompanied  by  any 
displacement.  The  spinal  membranes  were  healthy.  The  cord 
opposite  the  seat  of  fracture  was  not  at  all  compressed,  but  was 
for  a  distance  of  about  an  inch  very  soft  and  pulpy,  containing 
numerous  punctiform  haemorrhages,  which  were  most  marked  in 
the  central  grey  matter.     The  other  organs  were  not  examined. 

This  case  presents  an  interesting  comparison  with  Case  3  on 
the  one  hand,  and  with  Cases  i  and  2  on  the  other.  The  lesion 
of  the  spine  itself  was  less  severe,  and  there  was  less  displacement 
of  the  bones,  which  consequently  did  not  cause  permanent  com- 
pression of  the  cord.  There  was,  however,  ample  evidence  of  a 
temporary  crush  of  the  spinal  cord,  received,  no  doubt,  at  the  time 
of  injury,  the  bones  afterwards  partially  recoiling  to  their  normal 
position.  Such,  doubtless,  is  the  explanation  of  many  cases  (as, 
for  instance,  those  referred  to  in  the  following  chapter),  in  which 
there  is  little  or  no  evidence  of  bone-lesion,  but  in  which  the  cord 
itself  has  sustained  a  severe  injury.  An  accident  causes  an  acute 
bend  of  the  vertebral  column,  which  at  once  rights  itself,  but  not 
before  great  or  irreparable  damage  has  been  inflicted  upon  the  con- 
tained organ ;  and  many  of  these  cases  have  been  regarded  as  in- 
stances of  "concussion  of  the  spinal  cord,"  the  possibility  of  a  gross 
mechanical  lesion  being  overlooked.  Another  point  which  is  here 
exemplified,  but  which  is  more  fully  demonstrated  in  Case  16,  is 
the  tendency  for  haemorrhage  into  the  spinal  cord  to  affect  mainly 
its  central  portions,  where  its  substance  is  softest,  and  where  the 
large  branches  of  the  central  spinal  artery  have  their  distribution. 


INJURIES    TO    THE   CERVICAL   REGION.  1 3 

As  regards  the  distribution  of  the  paralysis  and  anaesthesia  in 
this  case,  we  find  that  there  was  not  complete  annihilation  of  the 
functions  of  the  two  fifth  cervical  nerves,  their  roots  not  having 
been  severely  nipped  between  the  affected  bones,  although  the 
cord  below  their  origin  was  crushed.  On  the  left  side  the  upper 
limb  was  completely  paralysed,  as  in  Cases  i  and  2,  but  on  the 
right  side  some  of  the  muscles  supplied  by  the  upper  root  of  the 
brachial  plexus  had  partially  escaped,  the  biceps  and  deltoid  not 
beiug  paralysed.  The  supinators  were,  however,  paralysed  on  this 
side  also,  a  result  perfectly  explicable  on  the  supposition  that, 
occupying  the  lowest  nucleus  connected  with  the  fifth  root,  they 
would  most  readily  come  within  the  sphere  of  pressure  due  to  the 
central  haemorrhage  immediately  below.  Further,  we  find  that,  as 
in  Case  3,  so  here,  sensation  was  retained  on  the  outer  border  of 
the  arm,  forearm,  and  hand  of  both  sides,  the  sensory  conducting 
paths  of  the  left  side  having  been  destroyed  up  to  a  rather  lower 
level  than  were  the  motor  functions.  Such  damage  as  was  done 
to  the  area  of  the  fifth  roots  must  therefore  be  ascribed  to  the 
central  hsemorrhage  rather  than  to  injury  of  the  roots  themselves. 


Case  5. — Comminuted  fracture  of  fifth  and  sixth  cervical  vertebrce 
— Partial  paralysis  of  left  upper  limb — Total  paralysis  of 
other  limbs  and  trunk — Death. 

W.  H.  was  admitted  to  Mr.  Whitehead's  wards  on  April  30, 
1886.  He  was  twenty-eight  years  of  age,  a  wine  merchant  by 
occupation,  and  of  intemperate  habits.  When  admitted,  he  was 
intoxicated,  and  had,  while  in  that  condition,  fallen  over  the 
railing  of  a  staircase,  the  distance  not  being  ascertained.  He 
complained  of  great  pain  at  the  back  of  the  neck,  but  there  were 
no  external  signs  of  injury.  There  was  complete  paralysis  of 
both  lower  extremities  and  of  the  right  upper  limb,  but  on  the 
left  side  he  could  bend  the  elbow-joint.  Respiration  was  diaphrag- 
matic. The  cutaneous  reflexes  and  tendon  reactions  were  abolished. 
Anaesthesia  was  complete  below  the  distribution  of  the  branches  of 
the  cervical  plexus,  except  over  a  portion  of  the  left  upper  limb. 
The  pupils  were  moderately  contracted,  the  contraction — or  rather 
imperfect  dilatation — showing  best,  as  is  usual  in  these  cases,  in 
diffused  light ;  the  palpebral  fissures  were  small.  The  pulse  was 
slow  and  compressible.  The  temperature  was  not  recorded,  but 
was  below  the  normal.  The  urine  was  retained,  and  the  penis  large 
and  turgid. 


H 


SURGERY    OF   THE    SPINAL    CORD. 


A  more  complete  examination  showed  that  although  there  was 
absolute  loss  of  motion  and  sensation  in  the  right  upper  extre- 
mity, the  paralysis  had  on  the  left  side  spared  the  deltoid,  biceps, 
brachialis  anticus  (?),  and  supinator  longus ;  the  pectoralis  major 
and  latissimus  dorsi,  and  all  the  muscles  below  the  shoulder,  with 
the  exception  of  those  mentioned,  were  paralysed.  The  limb  occu- 
pied exactly  the  position  assumed  by  those  of  Case  3,  being 
slightly  abducted  at  the  shoulder,  rotated  outwards,  with  the 
elbow  flexed  and  the  forearm  and  hand  supine,  the  contrast 
between  this  position  and  the  complete  flaccidity  of  the  right 
upper  extremity  being  very  striking.  This  was  the  first  case 
in  which  this  remarkable  position  of  the  limb  was  noted  in  the 
Manchester  Infirmary,  the  detection  of  its  significance  being  due 

to  Mr.  Collier,  then  resident 
surgical  officer.  Anaesthesia  ex- 
tended over  the  whole  of  the  left 
upper  extremity,  except  a  strip 
of  skin,  some  three  inches  wide, 
extending  downwards  from  the 
shoulder  along  the  outer  side  of 
the  limb  to  a  point  about  three 
inches  below  the  level  of  the 
elbow-joint. 

The  patient  complained  much 
of  diflBculty  of  breathing,  which 
increased  rapidly,  and  he  died 
asphyxiated  about  forty  hours 
after  the  accident.  Before  death 
the    temperature    became    very 

Fio.  2. — Third,  fourth,  fifth,  sixth,  and  seventh  -i  .     i 

cervical  vertebrae  from  Case  5,  seen  from  nign> 

the  front,  showing  a  comminuted  fracture  a  j.    il        _      t  .^  •_ 

of  the  bodies  of  the  filth  and  sixth  verte-  At   the    pOSt-mortem    examina- 

^™'  tion,  which  was  made  by  Dr.  Bury, 

then  medical  registrar,  there  was  found  a  complete  crush  of  the  body 
of  the  fifth  cervical  vertebra,  that  of  the  fourth  being  displaced 
downwards  and  forwards,  and  having  its  left  transverse  and  arti- 
cular processes  broken  off,  and  that  of  the  sixth  being  split 
vertically.  The  condition  of  the  bones  is  shown  in  fig.  2.  In 
front  of  the  bodies  of  the  injured  vertebrae  was  some  extravasation 
of  blood.  On  opening  the  spinal  canal,  the  cord  was  found  to  be 
obliquely  compressed  by  the  bony  fragments  in  such  a  way  that 
the  upper  limit  of  the  flattening  was  above  the  fifth  cervical  nerve- 
root  on  the  right  side,  but  between  that  and  the  sixth  nerve-root 
on  the  left,  as  shown  in  fig.  3,  a  small  piece  of  the  body  of  the 


INJURIES    TO    THE   CERVICAL   REGION. 


15 


fifth  vertebra  pressing  upon  the  origin  of  the  fifth  root  of  the  right 
side.     The  lungs  were  intensely  congested,  and  portions  of  the 
left  lower  lobe  sank  when   thrown  into 
water.      The    other    organs     presented 
nothing  of  interest. 

This  case,  like  the  preceding  one,  is 
an  instance  of  oblique  injury  to  the  cord, 
the  direction  of  the  obliquity  being  re- 
versed, and  the  fifth  root  escaping  on  the 
left  side  only ;  and  it  thus  offers  another 
illustration  of  the  distribution  of  the 
motor  and  sensory  branches  of  this  root. 
The  area  in  which  sensation  was  retained 
was  less  than  in  Cases  3  and  4,  owing 
possibly  to  some  of  the  lower  sensory 
fibres  of  the  left  fifth  root  being  also  in- 
volved in  the  lesion. 


Case  6. — Injury  to  upper  part  ofhracMal 
region — Paralysis  below  deltoid  nuclei 
— Death. 


Fig.  3. — Spinal  cord  from  Case  s, 
seen  from  behind,  showing 
compression,  extending obli-, 
quely  from  above  the  origin 
of  the  sixth  cervical  nerve  on 
the  left  side,  iipvyards,  so  as 
to  intercept  the  fifth  nerve- 
root  on  the  right  side. 


A  man  aged  thirty-five  was  admitted 
under  Mr.  Heath's  care  on  June  18, 
1887.  He  had  the  night  before  admission 
fallen  down  about  ten  steps  on  to  his  head,  as  evidenced  by  bruises 
on  the  left  side  of  the  cranium.  As  he  died  in  a  few  hours,  I  was 
obliged  to  obtain  my  information  from  Mr.  Thompson,  the  house- 
surgeon. 

At  the  back  of  the  neck  was  a  large  amount  of  effused  blood, 
but  the  spines  of  the  vertebrae  were  distinctly  felt,  that  of  the 
sixth  cervical  being  apparently  displaced  slightly  to  the  right. 
Beyond  this  there  was  no  deformity,  nor  any  difficulty  in  movement, 
and  the  man  complained  of  but  slight  pain  in  the  back  of  the  neck. 

The  lower  limbs  and  trunk  were  completely  paralysed ;  the 
arms  were  held  rigid  with  the  elbows  abducted,  and  the  hands 
lying  on  the  epigastrium  extended  and  prone.  Anassthesia  was 
complete  below  a  point  about  two  inches  above  the  nipples,  being 
also  complete  over  the  shoulders  and  in  the  upper  limbs.  The 
pupils  were  reduced  to  fine  points.  The  urine  was  retained  and 
the  penis  turgid. 


1 6  SURGERY    OF    THE   SPINAL   CORD. 

As  the  man  was  being  placed  in  bed,  respiration  became  slow 
and  gasping,  with  distinct  action  of  the  scaleni  and  sterno- 
mastoids;  the  patient  grew  cyanotic  and  respiration  then  stopped, 
the  pulse  ceasing  about  half  a  minute  later.  There  was  no  post- 
mortem examination. 

The  above  case  carries  us  but  little  further,  but  it  is  clear 
from  the  facts  adduced,  and  especially  from  the  anaesthesia  affect- 
ing the  whole  surface  of  the  upper  limbs,  that  almost  the  entire 
brachial  region  was  affected.  With  the  exception  of  the  abduction 
of  the  shoulders  and  flexion  of  the  elbows,  the  arms  were  in  the 
position  of  rest,  resulting  from  complete  paralysis.  Hence  then 
the  biceps  and  deltoid  had  escaped,  but  the  supinators  and  all 
muscles  mentioned  below  them  in  our  table  were  paralysed — that 
is  to  say,  the  haemorrhage  resulting  from  the  crush  of  the  cord 
had  extended  partially  into  the  territory  of  the  fifth  root,  destroy- 
ing the  nuclei,  at  its  lower  part,  for  the  supinators,  but  sparing 
the  biceps  and  deltoid  above.  This,  and  other  cases,  such  as  our 
fourth,  indicate  that  the  branches  to  the  supinators  have  the 
lowest  origin  of  the  "  fifth  root  group "  of  nerves,  these  being 
often  implicated  when  the  remainder  of  the  root  escapes  paralysis. 


Case  7. — Injury  to  upper  part  of  brachial  region — Paralysis  below 
biceps  nuclei — Death. 

A.  B.,  aged  twenty-three,  was  admitted  to  the  Manchester 
Infirmary  under  the  care  of  Mr.  Jones  on  April  7,  1888.  He 
was  playing  football,  and,  while  stooping  forwards  with  his  head 
thrown  up  in  order  to  "  tackle  "  an  opponent,  came  into  violent 
collision,  his  head  being  jerked  backwards.  He  was  immediately 
paralysed. 

On  admission,  the  spine  of  the  seventh  cervical  vertebra  was 
felt  to  be  distinctly  depressed,  but  with  little  or  no  lateral  dis- 
placement. There  was  a  good  deal  of  swelling  about  the  back  of 
the  neck,  and  the  patient  complained  of  great  pain.  The  lower 
limbs  and  trunk  were  completely  paralysed,  respiration  being 
diaphragmatic.  In  the  upper  limbs  the  only  muscles  not  para- 
lysed were  the  flexors  of  the  elbow.  The  limbs  at  first  lay  ex- 
tended and  close  to  the  body,  but  when  told  to  try  to  move  them, 
the  patient  bent  the  elbows  so  as  to  bring  the  hands  up  to  the 
shoulders.     The  pupils  were  slightly  contracted. 

An  attempt  was  at  once  made  to  reduce  the  dislocation  by 


INJURIES    TO    THE    CERVICAL   REGION.  1 7 

extension,  followed  bj  flexion,  of  the  neck,  and  a  distinct  jerking 
was  felt  by  the  assistants  who  were  steadying  the  trunk.  The 
patient  expressed  himself  as  feeling  his  pain  relieved,  but  no 
other  change  was  produced.  Later,  another  attempt  at  reduction 
was  made  under  chloroform,  but  with  equally  little  success.  The 
patient  was  now  put  to  bed,  the  head  being  steadied  by  pillows 
and  sandbags.  At  this  time  the  temperature  was  below  95°, 
and  the  skin  felt  cold ;  the  pulse  was  strong  and  regular ;  the 
penis  was  turgid,  the  urine  retained. 

About  4  A.M.  on  the  following  day  the  temperature  began  to 
rise  rapidly ;  the  skin  was  hot,  flushed,  and  perspiring ;  and  the 
patient  became  delirious.  At  6  A.M.  the  temperature  had  risen  to 
106.6°,  at  8  A.M.  to  108°,  and  at  9.30  to  110°,  at  which  time  the 
man  died  comatose. 

There  was  no  post-mortem  examination.  For  notes  of  the 
above  I  am  indebted  to  Mr.  Stocks,  the  house-surgeon. 

This  case  is  also  somewhat  unsatisfactory,  as  the  accident 
happened  on  Saturday  night,  and  the  man  died  on  the  Sunday 
morning,  so  that  it  was  not  very  fully  observed.  It  indicates 
the  high  position  of  the  nucleus  for  the  flexors  of  the  elbow,  and 
shows  that  the  deltoid  and  supinators,  also  supplied  by  the  fifth 
root,  were  paralysed.  Thus,  then,  as  in  Case  3,  we  are  led  to 
place  the  deltoid  nucleus  below  that  of  the  flexors  of  the  elbow. 
Hence  we  find  that  of  the  four  motor  nuclei  comprising  the  "  fifth 
root  group,"  the  lowest  is  that  for  the  supinator  longus  (and 
brevis  ?),  paralysed  in  Cases  4  and  6 ;  and  that  next  to  this  comes 
that  for  the  deltoid,  parah'sed  throughout  in  Case  7,  and  as  a  result 
of  ascending  myelitis  in  Case  3.  Thus  the  flexors  of  the  elbow 
would  appear  to  occupy  the  highest  position  of  the  segment — a 
result  which,  although  it  appeared  to  me  improbable,  I  cannot 
but  accept  on  the  evidence  of  these  and  other  cases,  such  as  the 
following,  in  which  again  the  flexors  of  the  elbow  were  alone 
spared  in  the  left  upper  limb. 


Case  8. — Fracture  of  fifth  cervical  mrtehra — Paralysis  helow  biceps 
nucleus  on  right  side  and  pronator  nvMeus  on  left — Trephining 
— Death. 

R.  R.,  aged  thirty-three,  was  admitted  to  the  Manchester  In- 
firmary, under  the  care  of  Mr.  Hardie,  on  November  21,  1888. 

B 


l8  SUEGEllY    OP    THE   SPINAL    CORD. 

Four  days  previously  he  had  been  struck  on  the  back  of  the 
neck  by  a  weight,  which  he  estimated  at  3  cwt.,  and  which  was 
hangfinof  from  a  chain.  The  head  was  forced  forwards  on  to  the 
chest.  He  did  not  lose  consciousness,  nor  present  any  signs  of 
cerebral  concussion  or  other  head-injury,  but  he  became  imme- 
diately paralysed.  Subsequently  to  the  time  of  the  accident  he 
did  not  think  any  change  had  occurred  in  his  condition. 

He  complained  of  pain  at  the  back  of  the  neck,  but  no  local 
deformity  could  be  detected.  The  lower  limbs  and  trunk  were 
completely  paralysed  and  anaBsthetic  below  the  descending  branches 
of  the  cervical  plexus.     Respiration  was  diaphragmatic. 

The  left  upper  limb  lay  with  the  humerus  straight  by  the  side, 
and  the  forearm  across  the  epigastrium.  The  only  movement 
which  could  be  effected  was  flexion  of  the  elbow,  which  was  accom- 
panied by  a  readily- felt  contraction  of  the  biceps.  The  right 
upper  extremity  had  no  fixed  position,  and  presented  a  greater 
range  of  movement,  flexion  of  the  elbow  and  abduction  of  the 
humerus  being  readily  performed,  while  there  was  slight  power  of 
adducting  the  humerus,  and  of  supinating  and  pronating  the  wrist. 
Sensation  was  much  better  on  the  outer  border  of  the  left  upper 
limb  than  in  any  other  portion  of  it,  and  was  almost  entirely  lost 
on  the  inner  aspect,  but  there  was  no  defined  limit ;  the  hand  was 
completely  anajsthetic  except  along  its  outer  border  and  over  the 
root  of  the  thumb.  In  the  right  upper  limb  the  limits  of  sensa- 
tion were  similar,  but  the  anaesthesia  was  less  complete. 

The  plantar  and  cremasteric  reflexes  and  the  knee-jerks  were 
absent. 

Both  palpebral  fissures  and  pupils  were  small,  and  the  latter 
did  not  dilate  on  pinching  the  skin  of  the  neck. 

The  urine,  which  was  retaiped,  was  neutral  (sp.  gr.  1023),  and 
contained  no  sugar,  albumin,  or  other  abnormal  constituent. 

The  temperature  was  99.6°.  The  penis  presented  no  turgidity. 
The  pulse  was  96,  small  and  soft.  The  skin  felt  dry  and  warm, 
and  presented  several  superficial  suppurating  sores  on  the  feet, 
thighs,  and  abdomen,  the  former  due  doubtless  to  the  use  of  hot 
bottles,  the  latter  admittedly  the  result  of  turpentine  stupes. 

On  November  22,  five  days  after  the  injury,  Mr.  Hardie  pro- 
ceeded to  trephine  the  spine.  The  back  of  the  neck  having  been 
shaved,  and  the  patient  lying  on  his  face,  with  the  head  over  the 
end  of  the  table,  and  supported  by  an  assistant,  a  median  incision 
was  made  over  the  cervical  spinous  processes,  and  carried  down 
to  the  bones.  The  soft  structures  were  reflected  to  either  side, 
partly  by  the  knife  and  partly  by  the  raspatory.      Haemorrhage 


INJURIES    TO    THE    CERVICAL   REGION.  1 9 

gave  a  little  trouble,  but  was  soon  checked  by  the  pressure  of 
sponges.  On  exposing  the  vertebral  arches,  the  fifth  cervical 
spinous  process  was  found  to  be  loose,  and  after  some  trouble  it 
was  wrenched  away  in  one  piece  with  the  left  lamina.  When  this 
fragment  of  bone  had  been  taken  away,  the  dura  mater  was  partly 
exposed,  and  the  right  lamina  of  the  sixth  cervical  arch  was 
also  found  to  be  fractured.  With  a  Hey's  saw,  supplemented 
by  the  bone-forceps,  the  left  lamina  of  this  arch  was  divided, 
and  the  posterior  portion  of  the  arch  thus  entirely  removed. 
The  exposed  dura  mater  appeared  perfectly  normal,  and  was  now 
obviously  free  from  compression  at  any  point.  A  large  drainage- 
tube  was  therefore  placed  in  the  wound,  which  was  sutured  and 
dressed  with  iodoform  and  wood-wool  pads.  The  spray  was  used 
throughout.  During  the  operation  respiration  ceased,  and  the 
patient's  condition  became  very  critical,  requiring  him  to  be 
turned  on  to  his  back  for  a  time,  with  the  use  of  artificial  respira- 
tion and  inhalation  of  nitrite  of  amyl. 

No  improvement  followed  the  operation,  and  very  shortly  after 
recovery  from  the  chloroform  the  patient  passed  into  gradually 
deepening  coma.  The  tem- 
perature rose  to  101°  on  the 
evening  of  the  day  of  opera- 
tion, and  reached  103.8°  the 
followinof  morninof.  It  then 
again  fell  rapidly  to  99.4°  in 
the  evening,  and  to  98°  on 
the  second  day,  when  the 
patient  died  comatose  and 
cyanotic.  He  thus  survived 
the  operation  by  forty-eight 
hours. 

At  the  post-mortem  I  re- 
moved only  the  affected  region 
of  the  spine,  the  condition  of 
which  is  fully  explained  by 
the  accompanying  illustration 
(tig.  4),  taken  from  a  sagittal 
section  previous  to  removal 
of    the    cord.      The    body   of 

the    fifth    cervical    vertebra    is   Fig.  4.— section  of  second  to  seventh  cervical  verte- 
T    ,    1  IT  -,  bra;,  the   arches   of  the  iiftb   and   sixth  beiuff 

completely  smashed,  and  pro-  removed,  and  the  body  of  the  fifth  fractured. 

jects   backwards,    distinctly    compressing   the    cord.      The   mem- 
branes were  uninjured. 


20  SUEGERY   OF   THE   SPINAL   CORD. 

The  right  upper  limb  of  this  patient  had  sufifered  less  severely 
that  the  left,  and  it  is  obvious  that  some  of  the  muscles  supplied 
by  the  sixth  cervical  root  had  escaped  paralysis.  We  shall  refer 
to  this  root  more  fully  directly,  but  may  note  in  passing  that  the 
muscles  here  spared  were  the  adductors  of  the  humerus  and  pro- 
nators of  the  wrist,  a  condition  corresponding  with  the  high 
position  given  to  their  nuclei  in  our  Table. 

The  following  is  another  instance  of  an  oblique  lesion  of  the 
cord,  including  in  the  damaged  area  the  origin  of  the  sixth  cervical 
root  on  the  left  side,  and  extending  upwards  on  the  right  so  as  to 
involve  that  of  the  fourth  and  fifth  roots.  The  reason  of  this 
obliquity  was  not  noted  at  the  post-mortem  examination,  but  it 
was  probably  due  to  a  higher  extension  of  the  central  haemorrhage 
on  the  right  side  of  the  grey  substance  of  the  cord. 


Case  9. — Dislocation  ofjifth  cervical  vertelra — Complete  paralysis 
of  right  upper  limh  ;  paralysis  helow  Jifth  root  nuclei  on  left 
— Trephining — Death. 

J.  C,  a  labourer,  aged  thirty-eight,  was  admitted  to  the 
Manchester  Royal  Infirmary,  under  the  care  of  Mr.  Hardie,  on 
October  25,  1887.  On  the  afternoon  of  this  day  he  had  fallen 
from  a  waggon  for  a  distance  of  about  six  feet,  striking  the  back 
of  his  shoulders  and  head.  He  was  immediately  paralysed,  but 
did  not  lose  consciousness. 

I  did  not  see  him  until  the  following  day,  but  am  informed  by 
the  house-surgeon  that  his  condition  on  admission  was  the  same 
as  when  he  came  under  observation. 

On  October  26  he  had  pain  across  the  shoulders,  shooting 
down  the  arms  to  the  elbows,  but  no  tenderness  of  the  spine  or 
pain  on  pressing  down  the  head.  There  was  some  arching  back- 
wards of  the  cervical  vertebrse,  but  no  lateral  deviation,  and  no 
obvious  deformity  of  the  spinous  processes. 

The  lower  limbs  were  absolutely  paralysed,  as  were  the  abdomen 
and  thorax,  respiration  being  diaphragmatic,  jerky,  1 8  per  minute, 
with  subjective  sense  of  dyspnoea  and  cough.  The  left  upper 
limb  was  abducted  at  the  shoulder,  with  the  elbow  flexed  and  the 
hand  across  the  chest ;  the  right  wais  completely  flaccid.  On  the 
left  side  the  patient  retained  the  power  of  voluntary  contraction 
of  the  supra-  and  infra- spinati,  biceps,  deltoid,  and  supinator 
longus,  but  not  of  the  other  limb-muscles,  whereas  on  the  right 
side  all  the  muscles  were  paralysed.      The   neck-muscles  were 


INJURIES   TO    THE    CERVICAL   REGION.  21 

normal  on  both  sides.  Both  palpebral  fissures  and  pupils  were 
smaller  than  usual,  but  not  so  markedly  so  as  in  many  cases. 

Anaesthesia  extended  as  high  as  the  level  of  the  third  ribs  in 
front  and  the  sixth  cervical  spine  behind,  but  on  the  right  side 
sensation  was  retained  over  the  region  of  the  deltoid  and  slightly 
beyond  it,  and  on  the  left  side  it  extended  over  the  area  of  the 
deltoid,  and  thence  down  the  outer  side  of  the  limb  to  about  the 
root  of  the  thumb,  becoming,  however,  very  vague  at  the  lower 
part.  The  anaesthetic  boundary  was  not  very  sharply  marked,  and 
had  no  adjoining  hypersesthesia. 

The  knee-jerk  and  plantar,  cremasteric,  gluteal,  and  epigastric 
reflexes  were  absent.  The  skin  felt  dry  and  warm,  although  the 
temperature  was  normal.  Urine  was  retained.  The  penis  was 
turgid,  but  less  so  than  on  the  previous  day.  Pulse  66,  feeble, 
and  with  a  very  marked  respiratory  wave,  being  full  and  soft 
towards  the  end  of  inspiration,  and  very  small  towards  the  end  of 
expiration. 

The  man's  condition  being  clearly  otherwise  hopeless,  Mr. 
Hardie  determined,  after  consultation  with  several  of  his  col- 
leagues, to  trephine  the  spine,  which  was  done  at  4.20  p.m.  on 
the  afternoon  of  the  day  after  admission,  about  twenty-four  hours 
after  the  injury.  For  the  subsequent  notes  I  am  indebted  to  Mr. 
Bannister,  the  house  surgeon. 

Chloroform  having  been  administered,  a  vertical  incision  about 
four  inches  long  was  made  over  the  cervical  spinous  processes, 
having  its  centre  opposite  the  fifth.  The  muscles  being  cleared 
from  the  laminae,  an  interval  of  about  a  quarter  of  an  inch  was 
found  between  the  fifth  and  sixth  spines,  and  the  fifth  vertebra 
appeared  to  be  slightly  displaced  forwards.  The  laminae  of  the 
fifth  and  sixth  vertebrse  were  now  removed  by  bone-forceps,  when 
the  dura  mater  was  exposed,  presenting  a  perfectly  normal  ap- 
pearance without  any  trace  of  haemorrhage.  As  nothing  further 
could  be  done,  the  dura  was  not  opened,  but  the  muscles  were 
brought  together  by  deep  catgut  sutures,  a  large  drainage  tube 
inserted,  and  the  wound  closed  over  a  smaller  superficial  drain. 
The  carbolic  spray  was  used  throughout,  and  wood-wool  pads 
used  as  a  dressing.  After  the  operation  brandy  was  given  at 
frequent  intervals. 

At  6  P.M.  the  pulse  was  54  and  feeble;  temperature  96°; 
respirations  13,  and  still  purely  abdominal.  At  10  p.m.  pulse 
74;  temperature  98.6°,  respirations  16.  The  patient  passed  a 
fairly  good  night,  but  in  the  morning  the  temperature  was  103.4°. 
On  the  afternoon  of  the  27th  he  became  suddenly  much  worse  j 


2  2  STJUGERY   OF   THE   SPINAL   COED. 

the  respirations  became  very  feeble  and  then  stopped ;  the  heart- 
beats, which  were  very  feeble  and  infrequent,  continuing  for  about 
ten  minutes  longer.  A  few  minutes  after  death  the  temperature 
in  the  mouth  was  104°. 

The  post-mortem  examination  was  made  by  Dr.  Harris.  The 
disc  between  the  fifth  and  sixth  cervical  vertebra  was  found  to 
be  ruptured,  the  former  bone  projecting  very  slightly  forwards. 
No  fracture  was  discovered.  The  dura  mater  was  uninjured,  but 
the  cord  was  flattened  opposite  the  seat  of  injury,  and  was  much 
contused  for  about  an  inch  above  and  below,  containing  haemor- 
rhages in  its  substance  and  in  the  central  canal ;  elsewhere  its 
structure  was  normal.  The  first  and  second  bones  of  the  sternum 
were  also  partially  separated,  and  the  lungs  much  congested. 

Having  thus  illustrated  the  functions  of  the  fifth  cervical  root, 
we  may  now  pass  to  the  consideration  of  cases  in  which  the  lesion 
is  situated  at  a  lower  level. 


Case  10, — Fracture-dislocation  of  fifth  cervical  vertebra — Partial 
destruction  of  brachial  region  of  cord — Death. 

J.  E.  C,  aged  thirty-three,  was  admitted  into  Mr.  Heath's 
wards  on  March  25,  1887,  at  2.30  P.M.  He  had  shortly  before 
been  "  larking  "  with  some  friends,  and  had  another  man  seated 
upon  his  shoulders,  when  he  was  pushed  in  the  face  backwards 
against  a  high  counter.  The  result  was  that  his  neck  was 
twisted  backwards,  the  man  falling  from  his  shoulders.  For  the 
first  few  minutes  he  only  noticed  pain  in  the  back  of  the  neck, 
but  then  his  legs  began  to  feel  weak,  and  he  lay  down :  within 
ten  minutes  the  lower  limbs  were  completely  paralysed  and 
insensitive,  and  he  found  that  he  could  not  straighten  the  left 
forearm. 

When  admitted,  there  was  paralysis  of  the  lower  limbs,  and 
the  left  upper  limb  was  only  partially  movable,  being  flexed  at 
the  elbow  and  somewhat  abducted  at  the  shoulder.  The  right 
limb  appeared  to  retain  more  power.  The  temperature  at  4  p.m. 
was  94.2°,  at  8  p.m.  97.6°,  and  at  midnight  99.2°,  near  which 
point  it  remained  for  some  days.  He  was  placed  in  a  water-bed, 
and  the  urine  withdrawn  by  the  catheter. 

On  the  following  morning  he  complained  of  pain  in  the  back 
of  the  neck,  but  there  was  no  local  deformity,  and  no  pain  on 
pressing  down  the  head.     The  lower  limbs  were  absolutely  para- 


INJURIES    TO    THE    CERVICAL    REGION.  23 

lysed,  as  were  tlie  abdominal  and  thoracic  muscles,  respiration 
being  diaphragmatic. 

The  left  upper  limb  lay  with  the  fingers  partially  flexed,  the 
wrist  straight,  hand  prone,  elbow  flexed,  and  the  humerus  abducted 
to  an  angle  of  about  45°  with  the  body:  he  often  raised  the 
humerus  above  the  shoulder,  otherwise  retaining  the  same  position, 
except  that  the  wrist  became  semi-prone.  He  could  not  extend  the 
elbow,  nor  flex  nor  extend  the  fingers,  but  on  attempting  to  flex 
the  fingers  there  was  slight  extension  of  the  wrist ;  he  had  also 
slight  power  of  flexion  and  extension  of  the  wrist,  but  this  move- 
ment was  extremely  limited :  pronation  and  supination  were  fairly 
good :  the  pectoralis  major,  latissimus  dorsi,  and  apparently  the 
subscapularis  contracted  very  feebly ;  the  biceps,  deltoid,  and 
supinator  longus  were  but  little  if  at  all  impaired. 

On  the  right  side  the  condition  was  practically  the  same,  except 
that  there  was  rather  more  power  in  the  wrist.  On  taking  a  deep 
breath,  the  sterno-mastoid,  trapezius,  and  levator  anguli  scapula 
contracted  very  distinctly  on  both  sides. 

As  regards  sensation,  there  was  a  subjective  "  feeling  of  heat " 
in  the  left  palm  and  forearm.  Anaesthesia  was  nowhere  complete, 
but  was  almost  so  below  the  level  of  the  third  ribs,  and  in  the 
upper  limbs  internally  to  a  plane  running  down  the  centre  of  the 
arms  and  forearms  to  the  styloid  processes  of  the  ulnae,  both  before 
and  behind.  Below  these  limits  there  was  absolute  analgesia,  but 
a  vague  sensation  was  conveyed  by  tickling.  The  limit  was  very 
ill-defined,  and  above  it  was  an  indistinct  hyperassthetic  zone. 

There  were  no  superficial  reflexes  nor  tendon  reactions. 

Urine  was  retained,  and  had  to  be  drawn  ofi"  by  the  catheter ; 
its  sp.  gr.  was  1024  ;  it  was  neutral,  and  contained  neither  sugar, 
albumin,  nor  any  deposit.  The  bowels  had  not  been  moved 
since  admission.  The  respirations  were  at  the  rate  of  19  per 
minute,  with  no  sense  of  dyspnoea,  but  slight  cyanosis.  Pulse 
69,  full  and  soft.  Skin  dry  and  warm.  The  penis  was  turgid. 
Both  palpebral  fissures  and  pupils  were  small,  and  there  was  no 
dilatation  of  the  pupils  on  pinching  the  neck. 

Two  days  later,  the  paralysis  of  the  upper  limbs  was  of  equal 
extent  on  both  sides.  There  was  complete  loss  of  power  in  all 
the  intrinsic  and  extrinsic  muscles  except  the  biceps,  deltoid, 
supinators,  and  subscapularis,  the  elbows  being  flexed,  the  humeri 
abducted  but  not  rotated  outwards,  and  the  hands  thus  lying  across 
the  chest.  The  pectoralis  major,  latissimus  dorsi,  and  teres  major 
had  become  quite  flaccid.  The  region  of  anaesthesia  in  the  upper 
limbs  had  also  extended.      The  temperature  was  normal.      The 


24  SURGERY    OF    THE   SPINAL    CORD. 

optic  discs  were  examined,  but  presented  no  abnormality.      Pria- 
pism was  less  marked. 

On  the  fourth  day  the  urine  contained  a  little  pns  (and  there- 
fore albumin),  but  no  sugar.      Its  reaction  was  acid. 

On  the  fifth  day  the  optic  discs  appeared  less  well  defined  than 
before,  and  presented  some  venous  congestion. 

On  the  sixth  day  the  subscapularis  and  supinator  longus  could 
no  longer  be  felt  to  contract,  but  the  arms  usually  occupied  the 
same  position  as  before,  although  during  sleep  they  were  often 
raised  above  the  shoulder.  He  complained  much  of  a  sense  of 
pain  and  stifihess  in  the  upper  limbs.  The  optic  discs  were  more 
vascular,  and  were  hazy — an  observation  which  was  confirmed  by 
Dr.  Little,  who  held,  however,  that  there  was  no  neuritis. 

For  a  few  days  sensation  in  the  trunk  and  lower  limbs  now 
seemed  to  improve  slightly,  but  the  patient  became  weaker,  and 
was  frequently  somewhat  delirious  at  night.  The  temperature 
ranged  from  ioo°  to  ioi°. 

On  the  eleventh  day  were  noted  tremors  of  the  paralysed 
muscles  of  the  upper  limbs.  A  day  later,  the  deltoid  and  biceps 
of  the  left  side  were  found  to  be  beginning  to  fail,  and  the 
humerus  was  less  abducted  than  formerly.  At  the  same  time 
sensation  began  to  fail  again. 

On  the  fourteenth  day  the  left  upper  limb  was  absolutely 
paralysed  and  anaesthetic,  the  humerus  lying  by  the  side,  the 
elbow  at  a  right  angle.  On  the  right  side,  the  only  muscle 
whose  contraction  could  be  felt  was  the  deltoid.  Ecchymoses 
had  formed  on  the  heels,  toes,  and  malleoli. 

On  the  fifteenth  day  a  distinct  knee-jerk  could  be  obtained  on 
the  right  side,  and  on  the  left  a  slight  reaction  was  present. 

A  few  days  later  he  developed  symptoms  of  pneumonia,  and 
the  condition  of  the  urine  became  much  worse.  The  temperature, 
which  had  regained  the  normal  on  the  fifteenth  day,  again  began 
to  rise  on  the  twenty-third,  keeping  a  fairly  steady  upward  curve 
until  the  twenty-ninth  day,  when  it  reached  104.6°,  and  death 
ensued.  During  the  later  period  there  was  obviously  more  rapid 
wasting  in  the  forearms  and  hands  than  in  other  parts  of  the 
body.  On  several  occasions  also  it  was  noted  that  the  passage 
of  the  catheter  was  accompanied  by  reflex  contractions  of  the 
sartorii. 

At  the  post-mortem  examination  I  found  some  separation  of 
the  fifth  and  sixth  cervical  spinous  processes.  The  body  of  the 
fifth  was  partially  dislocated  forward,  forming  a  very  obtuse  angle 
with  that  of  the  sixth,  and  overlapping  the  latter  anteriorly  by 


WBBS^  INJURIES    TO    THE    CERVICAL    REGION.  25 

about  a  line.  The  articular  processes  were  in  contact,  but  were 
partially  slipped  off  one  another.  The  upper  and  anterior  margin 
of  the  body  of  the  sixth  vertebra  was  very  slightly  ground  off, 
but  there  was  no  other  fracture.  The  vertebral  canal  contained 
a  little  dark  clotted  blood  at  the  seat  of  the  lesion.  The  cord 
was  here  partially  compressed  and  very  pale,  all  distinction  of 
white  and  grey  matter  being  lost.  This  condition  extended  only 
for  about  an  inch,  and  elsewhere  the  cord  presented  no  macro- 
scopic abnormality.  No  nerve-roots  were  crushed.  There  were 
marked  cystitis  and  double  pneumonia. 

"We  have  here  another  case  in  which,  after  the  cord  had  been 
crushed  below  the  fifth  cervical  nerve-roots,  the  muscles  supplied 
by  these  escaped  paralysis  for  a  considerable  time.  The  case 
differs,  however,  from  those  previously  mentioned,  in  that  the 
annihilation  of  the  functions  of  the  cord  below  the  lesion  was 
less  complete,  as  evidenced  by  the  fact  that  anassthesia  was  not 
absolute,  and  that  some  power  remained  in  many  of  the  muscles 
supplied  by  nerve-roots  distinctly  below  the  lesion.  The  examina- 
tion on  the  second  day  showed  that  whereas  the  flexors  of  the 
elbow,  deltoid,  and  supinators  retained  a  very  fair  amount  of 
power,  the  other  muscles  of  the  limb  were  paralysed  to  a  varying 
extent.  Thus,  next  to  the  "  fifth  root  group  "  in  order  of  power  we 
find  the  subscapularis,  pronators,  pectoralis  major,  and  latissimus 
dorsi,  between  which  no  distinction  could  be  drawn,  and  we  find 
also  that  the  extensors  of  the  wrist  still  retained  a  little  power. 
On  the  fourth  day  we  have  paralysis  of  all  the  muscles  supplied 
by  the  brachial  plexus,  except  the  "fifth  root  group  "  and  the  sub- 
scapularis, the  retained  tonus  of  the  latter  preventing  such  out- 
ward rotation  of  the  humerus  as  is  seen  in  fig.  i .  Again,  on  the 
sixth  day  the  subscapularis  and  supinators  fail,  and  later  the  del- 
toid and  biceps  begin  to  do  so.  As  there  can  be  little  doubt 
that  myelitis  was  extending  upwards,  we  may  then  accept  as  indi- 
cating the  arrangements  of  their  nuclei  from  below  upwards  the 
order  in  which  the  muscles  here  lost  their  power,  viz. : — 

1.  Intrinsic  muscles  of  the  hand  and  flexors  of  the  wrist  and 
fingers  immediately  completely  paralysed. 

2.  Extensors  of  wrist  almost  absolutely  paralysed  on  second 
day. 

3.  Pectoralis  major,  latissimus  dorsi,  teres  major,  and  pronators 
following  before  fourth  day. 

4.  Suhscapidaris  retaining  power  longer  than  any  muscles  but 
those  of  the  fifth  root. 


26  SURGERY    OF   THE    SPIXAL    COED. 

The  high  position  of  the  subscapularis  is  partially  confirmed 
by  Case  8,  already  referred  to  ;  and  in  the  latter  we  find  evidence 
that  the  pronators  are  supplied  from  a  neighbouring  point.  Thus, 
although  several  muscles  have  not  yet  been  localised,  the  arrange- 
ment of  our  Table  is  so  far  perfectly  illustrated. 


Case   i  i. — Diastasis  in  cervical  region — Partial  paralysis- 
Trephining — Death. 


J.  H.  M.,  a  railway  porter,  aged  thirty-nine,  was  admitted  to 
Mr.  Jones's  wards  on  September  22,  1888.  He  had  been  hurt  a 
few  hours  before  by  a  bale,  weighing  some  7^  cwt.,  falling  from 
the  second  floor  of  a  building  on  to  his  head  and  knocking  him 
backwards,  so  as  to  cause  the  back  of  his  head  and  neck  to 
strike  against  a  waggon.  He  did  not  lose  consciousness,  but 
experienced  immediate  paralysis  of  sensation  and  motion  in  the 
trunk  and  limbs. 

He  complained  of  pain  in  the  back  of  the  neck,  the  shoulder- 
blades,  and  "  all  the  joints  of  the  upper  limbs,"  with  cramps  in  the 
arms,  but  had  no  sensation  in  the  trunk  or  lower  limbs.  The  back 
of  the  neck  was  very  tender,  and  the  fifth  cervical  spine  could  not 
be  felt,  those  of  the  sixth  and  seventh  cervical  vertebrae  being 
prominent,  with  a  gap  above  them.  Pressure  downwards  upon 
the  head  caused  pain  in  this  region. 

He  lay  with  the  right  humerus  abducted  almost  to  a  right 
angle,  the  elbow  fully  flexed,  and  the  wrist  supine,  the  hand  lying 
on  the  pectoralis  major.  The  left  humerus  was  less  markedly 
abducted,  and  the  elbow  was  flexed  to  about  a  right  angle,  so 
that  the  left  hand  lay  on  the  right  side  of  the  chest.  Hence  we 
had  the  position  characteristic  of  a  lesion  of  the  cord  below  the 
fifth  cervical  nerve-roots.  On  examination,  it  was  found  that  he 
had  slight  power  of  moving  his  lower  limbs ;  respiration  was 
entirely  abdominal ;  in  the  upper  limbs  all  the  intrinsic  and 
extrinsic  muscles  were  paralysed  except  the  supra-  and  infra- 
spinati,  biceps  (brachialis  anticus  ?),  deltoid,  and  supinator  longus. 

The  knee-jerk  and  plantar  reflex  were  increased ;  the  cremas- 
teric and  abdominal  reflexes  could  not  be  elicited. 

Anassthesia  extended  up  the  trunk  as  high  as  to  the  level  of  the 
sixth  dorsal  nerve,  and  above  this  sensation  was  very  deficient 
until  the  area  supplied  by  the  descending  branches  of  the  cervical 
plexus  was  reached.  In  the  upper  limbs  there  was  sensation  only 
over  the  deltoid,  down  the  outer  side  of  the  upper  arm  and  forearm, 


INJURIES    TO   THE   CERVICAL    REGION.  2'] 

and  very  slightly  in  the  hands.  On  the  boundary-line  of  the 
anaesthesia  was  slight  hyperaesthesia. 

The  pupils  and  palpebral  fissures  were  contracted.  Urine  was 
passed  unconsciously,  and  the  bladder  was  empty.  He  had  never 
any  priapism.  The  pulse  was  60,  full  and  soft;  temperature 
normal. 

On  the  following  day  the  urine  was  found  to  be  faintly  alkaline, 
with  a  sp.  gr.  of  1008  ;  it  contained  no  albumin  or  sugar,  but 
gave  a  deposit  of  phosphates  and  mucus. 

On  the  third  day  the  wrists  were  distinctly  less  supinated, 
the  left  humerus  was  rather  more  and  the  right  rather  less 
abducted  than  on  admission,  so  that  the  two  upper  limbs  were 
now  in  the  same  position.  The  urine  had  a  sp.  gr.  of  1023, 
and  contained  a  heavy  deposit  of  urates  ;  it  was  still  voided  uncon- 
sciously, without  distending  the  bladder.  He  mentioned  that  he 
had  had  a  free  flow  of  "  salty  water  "  from  his  eyes,  and  the  face 
was  a  good  deal  congested.  The  pulse  was  48,  with  an  occa- 
sional intermission  ;  temperature  normal. 

On  the  fourth  day  the  arms  lay  closer  to  the  sides,  and  the 
elbows  were  less  flexed,  so  that  the  hands  lay  near  the  umbilicus. 
Sensation  in  the  trunk  and  lower  limbs  was  unaltered,  but  slight 
sensation  now  existed  in  the  whole  of  the  upper  limbs.  The 
knee-jerks  were  still  exaggerated,  the  plantar  reflex  of  about 
normal  vigour.  During  the  previous  day  Mr.  Giles,  the  house- 
surgeon,  had  noticed  that  in  the  morning  the  left  hand  was 
warmer  and  redder  than  the  right ;  in  the  evening  the  condition 
was  reversed.  On  this  day,  I  again  found  the  left  redder  and 
congested.  The  pupils  and  palpebral  fissures  were  small  but 
equal.  The  profuse  lachrymal  secretion  had  ceased.  The  urine 
was  ammoniacal  (sp.  gr.  1023). 

Three  days  later  the  arms  lay  straight  by  the  sides ;  the  man 
could  flex  his  elbows  and  rotate  the  humeri,  but  could  not  perform 
any  other  movements.  He  had  slight  sensation  in  the  lower  limbs, 
especially  in  the  feet.  The  right  knee-jerk  had  now  disappeared 
and  the  left  was  much  diminished.  The  formerly  exaggerated 
plantar  reflexes  could  no  longer  be  obtained. 

On  the  eleventh  day  he  felt  very  ill  and  was  much  weaker ; 
the  knee-jerks  were  again  well  marked. 

On  the  thirteenth  he  had  ceased  to  have  any  power  of  moving 
the  upper  limbs.  At  this  time  there  came  on  very  painful  feel- 
ings of  cramp  in  the  upper  limbs  and  stomach,  and  he  was 
hardly  able  to  obtain  any  sleep  on  account  of  the  pain. 

Four  days  later  he  had  much  more  power  in  the  biceps  and 


28  SUHGERY  OF    THE   SPINAL    CORD. 

deltoid,  and  slight  power  in  the  left  triceps.  The  knee-jerks  were 
now  and  hereafter  exaggerated.  The  optic  discs  were  hazy,  and 
their  vessels  slightly  congested. 

On  the  nineteenth  day  pain  in  the  limbs  persisted  as  before. 
Considerable  power  was  manifested  by  the  biceps,  deltoid,  and 
supinators ;  on  supination,  contraction  could  be  readily  felt  in 
the  supinator  brevis,  as  well  as  in  the  longus.  The  lower  part  of 
the  pectoralis  major  and  the  subscapularis  could  be  felt  to  be 
tonically  contracted  (the  arms  as  before  lying  by  the  sides),  and 
he  could  still  further  contract  them  voluntarily.  No  contraction 
could  be  felt  in  the  teres  major  and  latissimus  dorsi ;  there  was 
very  slight  power  in  the  triceps.     Hence  he  could — 

1.  Flex  the  elbow  by  the  Mceps  powerfully. 

2.  Abduct  the  humerus  by  the  deltoid  powerfully. 

3.  Supinate  the  wrist. 

4.  Adduct  the  humerus  by  the  pectoralis  major  and  sub- 
scapularis. 

5.  Extend  the  arm  by  the  triceps  feebly. 

6.  Pronate  by  the  action  of  gravity  only,  i.e.,  by  so  rotating 
the  humerus  that  the  hand  fell  into  the  prone  position. 

7.  He  had  no  power  over  the  forearm  or  hand-muscles. 
Sensation  was  unaltered.     The  right  optic  disc  now  presented 

no  abnormality,  the  left  was  still  hazy. 

On  the  twentieth  day  the  optic  fundi  were  examined  by  Dr. 
Little,  who  reported  that  the  right  was  perfectly  normal ;  the  left, 
however,  was  hazy,  with  some  distension  of  the  vessels  and  a  little 
haziness  along  their  course ;  hence  there  was  a  distinct  patholo- 
gical change,  indicated  especially  by  the  differences  between  the 
two  eyes. 

On  the  twenty-sixth  day  the  patient  had  rather  more  power  in 
the  triceps,  and  appeared  to  have  a  little  in  the  pronators.  There 
was  little,  if  any,  anaesthesia  of  the  upper  limbs,  but  that  of  the 
trunk  was  unaltered. 

On  the  thirty-fourth  day  the  pronator  teres  could  be  distinctly 
felt  to  contract,  and  there  was  the  slightest  possible  power  of  flex- 
ing the  fingers  of  both  hands,  but  the  wrists  remained  immovable. 
The  limbs  could  be  placed  and  would  lie  in  any  position.  Cramps 
were  much  less  severe,  but  the  lower  limbs  were  drawn  up  at  the 
hips  and  knees.  The  knee-jerks  were  very  slight.  Both  optic 
discs  were  again  alike,  the  right  being  more  hazy  than  before,  the 
left  less  so.  The  urine  was  very  foul.  The  temperature  generally 
remained  normal. 

In  the  beginning  of  November,  five  weeks  after  the  injury,  the 


INJURIES   TO   THE   CERVICAL   REGION.  29 

discs  were  quite  clear,  and  healthy-looking,  Dr.  Little's  report 
at  this  time  being  "  both  optic  nerves  quite  healthy  and  alike, 
well  defined,  and  no  haziness  whatever," 

The  patient  could  feebly  flex  or  extend  the  wrist  and  adduct 
the  thumb.  The  lower  limbs  were  in  a  condition  of  strong  tonic 
spasm  with  flexion  of  all  joints,  and  any  attempt  at  moving 
them  caused  much  pain.  Neither  superficial  nor  deep  reflexes 
could  be  obtained. 

From  this  time  forward  there  was  no  change  of  importance, 
except  that  the  temperature  became  irregular,  as  a  result  probably 
of  the  cystitis.  Pain  continued  to  be  very  severe,  and  there  was 
steady  emaciation.      It  was  now  decided  to  trephine  the  spine. 

On  November  17,  1888,  i.e.,  fifty-six  days  after  the  injury, 
the  back  of  the  neck  having  been  shaved  and  carefully  washed, 
chloroform  was  administered.  Mr.  Jones  made  an  incision  about 
five  inches  long  in  the  middle  line,  from  the  tip  of  the  third  to  that 
of  the  seventh  cervical  spinous  process.  This  incision  was  at  once 
carried  down  to  the  supra-spinous  ligament,  and  the  soft  parts 
reflected  to  either  side  by  means  of  the  knife.  Very  slight 
haemorrhage  was  caused.  The  fifth  cervical  spinous  process  was 
found  to  be  broken  off"  and  displaced  forwards,  and  its  vertebra 
slightly  rotated  to  the  left,  the  left  transverse  process  being  on  a 
plane  posterior  to  that  of  the  right.  The  fifth  spinous  process  was 
first  extracted,  and  then  by  means  of  a  chisel,  followed  by  the  use 
of  ordinary  bone-forceps,  the  laminas  of  the  fift:h  vertebra  were 
divided  on  each  side,  so  that  the  posterior  part  of  its  arch  could 
be  removed.  In  the  same  way  the  arch  of  the  sixth  was  taken 
away.  This  proceeding  exposed  the  posterior  aspect  of  the  dura 
mater,  which  was  smooth  and  of  a  normal  colour,  but  projected 
somewhat  backwards,  as  if  distended.  All  pressure  being  thus 
apparently  removed,  the  wound  was  washed  out  with  a  solution  of 
perchloride  of  mercury  (one  part  in  3000),  and  dusted  with  dry 
boracic  acid.  A  laro^e  drainaj^e-tube  was  inserted,  the  wound 
sutured,  and  dressed  with  dry  carbolised  gauze  and  wood-wool 
pads.  The  spray  was  not  used.  When  the  man  was  returned 
to  bed,  his  head  was  supported  between  sandbags. 

In  the  evening  the  temperature  was  99.8°,  but  the  patient 
appeared  perfectly  well.  For  the  next  three  days  there  was  no 
apparent  change,  and  the  temperature  gradually  returned  to  the 
normal. 

On  November  20  the  morning  temperature  was  97- 8°'  The 
arms  had  returned  to  the  characteristic  position  of  abduction  of 
the  humeri  and  flexion  of  the  elbows,  but  adduction  of  the  humeri 


30 


SURGERY    OF   THE   SPINAL   CORD. 


could  still  be  effected  by  voluntary  effort.     In  the  evening  the 
temperature  rose  to  100.4°. 

November  21. — The  wound  was  dressed,  and  very  little  dis- 
charge found.  Except  at  the  lower  end,  where  the  drainage- 
tube  projected,  its  surface  was  healed,  and  all  sutures  were  now 
removed,  the  drainage-tube  being  left.  The  temperature  con- 
tinued to  rise,  reaching  103.2°  in  the  evening.  Pain  in  the 
limbs  was  much  less  than  before  the  operation. 

November  23. — The  temperature  still  remained  high.  The 
arms  were  motionless  and  had  fallen  to  the  sides,  the  elbows  being 
flexed.  Contractions  could  be  felt  distinctly  in  the  biceps  only, 
and  very  slightly  in  the  deltoids. 

From  this  time  the  man  grew  rapidly  worse,  becoming  cyanotic, 
and  finally  comatose.  The  temperature  rose  to  105°,  and  he  died 
at  midday  on  November  25. 

In  making  the  post-mortem  examination,  I  removed  only  the 
spinal  cord  and  a  part  of  the  spine.     The  condition  of  the  latter 

will  be  best  understood  from 
the  following  engraving  (fig.  5), 
taken  from  a  photograph  of  a 
sagittal  section.  The  cartilages 
between  the  second  and  third 
and  the  third  and  fourth  cervi- 
cal vertebrge  were  broken,  and 
there  had  evidently  been  severe 
over-flexion  in  this  region,  caus- 
ing some  compression  of  the 
upper  anterior  edge  of  the  body 
of  the  third  cervical  vertebra, 
but  no  fracture.  The  bones  had 
then  returned  to  their  positions, 
leaving  the  spinal  canal  free 
from  any  permanent  compres- 
sion. The  spinal  membranes 
were  much  congested  through- 
out their  whole  extent.  The 
cord  itself  was  soft  and  difiluent 
opposite  the  fourth,  fifth,  and 
sixth  cervical  vertebrae.  From 
these  appearances  it  will  be 
obvious  that  there  had  been 
over-flexion  of  the  cervical  region  of  the  spine,  and  that  although 
the  greatest  damage  to  the  vertebral  column  was  situated  opposite 


Fig.  5. — Section  of  second  to  seventh  cervical 
vertebrse,  t}ie  arches  of  the  fifth  and  sixth 
beinff  removed. 


INJURIES    TO    THE   CERVICAL    REGION.  3 1 

the   third  cervical  vertebra,  the  cord   had  suffered  mainly  from 
haematomyelia  opposite  the  fifth. 

lu  this  case  we  find,  on  admission,  the  condition,  already  fully 
described,  in  which  the  nuclei  of  the  fourth  and  fifth  cervical 
nerve-roots  are  spared,  but  those  of  the  sixth  and  inferior  roots 
are  compressed  by  haemorrhage.  Shortly  afterwards  myelitis 
ensues,  and  on  the  second  day  we  have  paralysis  of  the  supina- 
tors ;  on  the  fourth,  of  the  deltoids ;  and  on  the  eleventh,  of  the 
flexors  of  the  elbows  and  muscles  supplied  by  the  fourth  root. 
Recovery  then  commences,  and  there  is  some  absorption  of 
the  haemorrhage  into  the  cord,  which  appears  to  restore  the 
functions  of  the  nuclei  in  order  from  above  downwards.  Thus 
the  fifth  root  group  of  muscles  is  the  first  to  recover ;  then  follow 
the  adductors  of  the  humerus,  and  to  a  less  extent  the  extensors 
of  the  elbow,  the  forearm  and  hand-muscles  remaining  paralysed 
on  the  eighteenth  day.  The  only  deviation  from  the  order  of 
our  Table  is  the  continued  paralysis  of  the  pronators ;  but  the 
contractions  of  these  muscles  are  among  the  most  difficult  to 
identify,  owing  to  the  interference  of  gravitation  in  the  position 
of  the  hand,  and  I  could  not  be  sure  of  their  paralysis.  A  few 
days  after  the  stage  above  referred  to  they  undoubtedly  regained 
power.  Lastly,  the  extensors  and  flexors  of  the  wrist  and  fingers 
and  the  adductors  of  the  thumb  regain  slight  power.  In  this 
condition  tlie  patient  remained  until  the  operation,  after  which 
myelitis  was  re-established,  and  the  nuclei  below  those  of  the  fifth 
root  were  again  rapidly  paralysed,  leaving  us  finally  with  a  lesion 
of  the  same  extent  as  on  admission. 


Case  12. — Fracture-dislocation  of  seventh  cervical  vertebra — Crush 
of  cord  in  region  of  lowest  brachial  nuclei — Ascending  myelitis 
— Death. 

J.  S.  was  admitted  to  the  Manchester  Royal  Infirmary  under 
the  care  of  Dr.  Morgan  on  February  5,  1887,  about  10. 30  P.M. 
He  had  been  at  a  place  of  entertainment,  and  when  drunk  had 
fallen  from  a  gallery  some  ten  feet  in  height,  but  it  was  not 
known  how  he  struck  himself. 

It  was  nearly  twenty-four  hours  after  his  admission  when  I 
first  saw  him,  and  when  he  presented  the  following  symptoms. 
The  lower  limbs  and  trunk  were  completely  paralysed,  respiration 
being  diaphragmatic.      In  the  upper  limbs  movements  were  nor- 


32  SURGERY   OF   THE   SPINAL  CORD. 

mal,  with  the  following  exceptions : — The  intrinsic  muscles  of  the 
hand  were  paralysed,  the  fingers  being  flexed  and  their  extensors 
(i.e.,  the  interossei  and  extensor  communis  digitorum)  paralysed, 
whilst  any  attempt  to  completely  flex  them  caused  slight  exten- 
sion of  the  wrist ;  the  wrist  was  held  straight,  both  its  extensors 
and  flexors,  but  especially  the  latter,  being  very  weak.  On  the 
right  side  the  extensors  of  the  wrist  were  weaker  than  on  the 
left.  The  lower  limbs  were  completely  anaesthetic,  as  was  the 
trunk,  as  high  as  the  level  of  the  second  rib  in  front  and  the 
spine  of  the  seventh  cervical  vertebra  behind.  In  the  upper 
limbs  anaesthesia  was  limited  with  the  greatest  accuracy  to  the 
inner  side  of  the  arm  and  forearm,  being  bounded  in  front  by  a 
line  running  vertically  from  the  front  of  the  deltoid  opposite  the 
second  rib,  down  the  centre  of  the  biceps  and  forearm  to  the 
middle  of  the  wrist ;  similarly  behind  the  boundary  was  a  vertical 
line  down  the  centre  of  the  triceps  and  back  of  the  forearm  to 
the  centre  of  the  wrist.  In  the  hand  the  limiting  line  sloped, 
both  in  front  and  behind,  from  the  centre  of  the  wrist  to  the 
cleft  between  the  fourth  and  fifth  fingers,  the  little  finger  being 
completely  anaesthetic,  the  others  not  at  all  so.  There  was  no 
trace  of  hyperaesthesia. 

Superficial  and  tendon  reflexes  were  all  absent.  Both  palpebral 
fissures  were  distinctly  small,  as  were  the  pupils,  the  diminution 
of  the  latter  being,  as  usual,  especially  notable  in  a  dim  light. 
The  pupils,  moreover,  did  not  dilate  on  pinching  the  skin,  but 
they  showed  very  marked  dilatation  on  each  inspiration.  Urine 
was  retained.  Penis  turgid.  Pulse  80.  Temperature,  mane  98°, 
vesp.  99.4°. 

On  the  following  morning  some  additional  points  were  noted. 
The  patient  had  no  pain  anywhere,  but  described  a  sense  of  stifi"- 
ness  in  the  upper  limbs,  and  no  pain  was  caused  by  pressing  or 
jerking  the  head  downwards.  The  seventh  cervical  spine  was 
thought  to  be  rather  more  prominent  than  usual.  Kespiration 
was  mainly  diaphragmatic,  aided  by  the  upper  scapular  and 
stemo-mastoid  muscles;  it  was  at  the  rate  of  24  per  minute, 
without  sense  of  dyspnoea.  He  had  slight  cough  and  some  collec- 
tion of  mucus  in  the  bronchial  tubes.  The  plantar,  cremasteric, 
abdominal,  and  epigastric  reflexes,  and  the  tendon  reactions  at 
the  ankle,  knee,  wrist,  and  elbow,  were  all  absent.  The  urine 
had  a  specific  gravity  of  1028,  and  contained  neither  sugar  nor 
albumin.  The  pulse  was  80,  soft,  and  feeble ;  sphygmographic 
tracings  taken  from  the  radial  and  the  posterior  tibial  arteries 
showed  nothing  unusual  in  either  vessel.     The  heart  was  normal. 


INJURIES    TO    THE    CERVICAL    REGION.  33 

The  skin  felt  dry  and  warm,  although  at  this  time  the  axillary- 
temperature  was  only  96.2°,  but  the  chest  and  abdomen  were 
moister  than  the  limbs ;  there  was  no  redness  or  trace  of 
soreness. 

On  the  third  day  the  patient  felt  better,  especially  as  he  had 
been  troubled  with  vomiting,  which  had  now  ceased.  He  had 
less  power  over  the  fingers  and  wrist,  the  former  being  flexed, 
the  latter  extended  and  without  power  of  movement.  Dr.  J.  C. 
Thresh,  the  clinical  clerk,  called  my  attention  to  the  fact  that  the 
urine  (specific  gravity  1031)  completely  solidified  with  cold  nitric 
acid,  owing  to  the  formation  of  nitrate  of  urea.  The  optic  discs 
were  a  little  hazy,  with  slight  venous  congestion.  On  February 
10  the  discs  were  again  examined  by  Dr.  Little,  who  noted  these 
symptoms,  but  could  not  definitely  assert  that  there  was  any 
pathological  change. 

These  symptoms  continued  without  any  important  change  until 
the  seventh  day,  when  it  was  found  that  on  both  sides  the  patient 
had  lost  the  power  of  rotating  the  wrist  or  extending  the  elbow, 
and  that  no  contraction  could  be  felt  in  the  triceps  muscles.  The 
fingers  and  wrists  were  flexed  and  completely  paralysed.  The 
pectoralis  major  on  either  side  was  also  now  paralysed,  but  the 
latissimus  dorsi,  teres  major,  and  subscapularis  could  be  felt  to 
contract  on  voluntary  effort.  The  position  of  rest  of  the  upper 
limbs  was  now  as  follows  :  the  humerus  abducted  almost  to  a  right 
angle  and  slightly  rotated  inwards,  the  elbows  fully  flexed,  the 
wrists  prone,  and  the  hands  across  the  chest  with  the  wrists  and 
fingers  flexed.  Breathing  was  much  more  difficult ;  he  presented 
some  signs  of  mental  hebetude  :  the  whole  body  was  dry  and 
cold,  and  the  urine  was  still  loaded  with  urea  and  phosphates  (in 
solution),  having  a  specific  gravity  of  1033. 

On  the  following  day  the  subscapularis  could  no  longer  be  felt  to 
contract,  and  the  latissimi  were  weaker,  the  teres  major  remaining 
about  the  same  as  the  day  before.  The  humerus  was  now  rotated 
externally  more  readily  than  internally,  thus  differing  from  the 
condition  of  the  previous  day,  and  it  was  a  greater  effort  to  bring 
it  towards  the  side.    A  little  redness  had  appeared  over  the  malleoli. 

On  the  ninth  day  we  found  that  the  boundary  of  absolute 
anaesthesia  was  the  same  as  on  admission,  but  some  dulness  of 
sensation  extended  further  outwards  on  the  limb.  The  motor 
symptoms  were  unaltered.  The  optic  discs  had  become  more 
indistinct  than  before,  and  the  small  vessels  were  quite  obscured. 
Dr.  Little  concluded  that  there  was  now  definite  optic  neuritis. 

During  the  evening  of  this  day  he  vomited  freely  both  food  and 

c 


34 


SURGERY    OF    THE    SPINAL    CORD. 


"  coffee-grounds,"  and,  becoming  delirious,  died  about  I   a.m.  on 
February  15,  the  tenth  day  after  the  accident. 


The  above  chart  shows  the  very  low  temperature  which   was 
maintained  during  the  entire  duration  of  the  case. 


INJURIES    TO    THE    CERVICAL   REGION.  35 

At  the  post-mortem  examination  was  found  a  fracture  of  the 
anterior  and  upper  part  of  the  body  of  the  first  dorsal  vertebra, 
a  small  portion  being  chipped  off  and  remaining  attached  to  the 
disc  above.  The  seventh  cervical  vertebi'a  was  displaced  forwards, 
carrying  with  it  the  above-mentioned  fragment  of  the  first  dorsal. 
The  laminee  of  these  two  vertebrae  were  separated  behind,  the 
articular  processes  of  the  first  dorsal  being  posterior  instead  of 
anterior  to  their  fellows  of  the  seventh  cervical.  On  opening  the 
spinal  canal,  there  was  found  slight  effusion  of  blood  between  the 
bone  and  the  dura  mater.  The  cord  was  compressed  at  the  level 
of  the  first  dorsal  vertebra,  and  softened  for  a  short  distance  above 
and  below  the  site  of  compression,  its 
centre  being  occupied  by  an  effusion 
of  blood  reaching  as  high  as  the  fifth 
cervical  nerve-roots,  in  the  form  of  a 
narrow  cone.  There  was  some  sup- 
puration between  the  anterior  common 
ligament  of  the  spine  and  the  fiith 
cervical  vertebra,  and  at  exactly  corre- 
sponding points  on  the  anterior  and 
postei'ior  walls  of  the  pharynx. 


This  interesting  case  is  in  itself  al- 
most a  demonstration   of  the   greater 
part  of  our  Table.     The  injury  was  at 
the  extreme  lower  part  of  the  cervical 
region,  and  must  at  first  have  involved 
the  origin  of  the  first  dorsal   nerves, 
and  probably  to  some  extent  that   of 
the  eighth  cervical.      Thus  at  first  we 
had    paralysis    only    of    the    intrinsic   no.  y.-sketch  of  section  of  spine  in 
muscles  of  the  hand  and  the  interossei,       fSoV  J^t^Tlvfnr'c^r'Si 
but  thereafter    from    day   to    day   we       '^^ertebra. 
were  able  to  watch  the  extension  upwards  of  myelitis,  picking  out 
muscle  by  muscle  in  the  following  order  : — 

1.  The  flexors  of  the  wrist. 

2.  The  extensors  of  the  wrist. 

3.  The  triceps  and  pectoralis  major. 

4.  The  latissimus  dorsi. 

5.  The  teres  major  and  subscapularis. 

6.  The  deltoids,  flexors  of  the  elbow,  aud  external  rotators  of 
the  humerus  (supra-  and  infra-spinati)  remained  until  the  last. 

The  dates  at  which  the  pronators  failed  could  not  be  obtained. 


36  SURGERY    OF   THE    SPIXAL    CORD. 

In  conclusion,  we  may  refer  to  two  more  cases,  completing  the 
series  of  fatal  fractures  in  the  cervical  region  which  have  come 
under  my  observation.  Both  these  cases  are  characterised  by  the 
fact  that  extensive  haemorrhage  into  the  cord  caused  the  paralytic 
symptoms  at  once  to  extend  higher  than  the  level  of  the  crush, 
an  occasional  result  which  makes  it  necessary  to  avoid  too  hastily 
diagnosing  the  site  of  a  fracture  from  the  extent  of  nervous 
symptoms  only. 


Case  i  3. — Fracture-dislocation  of  sixth  cervical  vertebra — Exten- 
sive hcemorrhage  into  cord — Death. 

E.  M.,  a  woman,  aged  forty-three,  was  admitted  under  the 
care  of  Mr.  Heath,  on  December  5,  1886,  on  which  day,  about 
1 1  A.M.,  she  had,  while  intoxicated,  fallen  down  some  twelve 
steps.  She  was  unconscious  for  a  short  time,  and  on  recovering 
found  that  she  had  lost  all  power  of  moving  the  trunk  and  limbs. 
She  was  brought  to  the  Infirmary,  and  admitted  about  5.15 
P.M.  on  the  day  of  the  accident. 

On  admission  she  was  very  drunk,  and  a  complete  examination 
was  impossible.  The  skin  felt  very  cold,  and  the  temperature 
was  below  95°,  but  no  thermometer  of  a  lower  register  was  at 
hand.  The  pulse  could  not  be  felt.  There  was  no  sweating. 
She  complained  of  pain  behind  the  shoulders,  but  there  was  no 
deformity.  The  lower  extremities  and  the  left  upper  limb  were 
entirely  paralysed  and  flaccid.  On  the  right  side  the  shoulder 
was  abducted,  and  rotated  somewhat  outwards,  the  elbow  being 
flexed,  the  wrist  and  fingers  flaccid.  Respiration  was  diaphrag- 
matic. The  urine  was  retained.  Owing  to  the  vagueness  of  her 
answers,  it  was  impossible  to  ascertain  the  limits  of  sensation, 
but  there  appeared  to  be  anaesthesia  below  the  neck.  The  right 
pupil  was  small,  distorted,  and  immovable,  owing  to  posterior 
synechia ;  the  left  was  small,  but  responded  both  to  light  and 
accommodation. 

When  I  examined  her  on  the  following  morning,  the  patient 
presented  the  following  symptoms : — The  intellect  was  perfectly 
clear,  and  she  gave  rationally  the  above  account  of  her  accident. 
She  presented  total  paralysis  of  all  four  limbs,  and  of  the  muscles 
of  the  chest  and  abdomen.  She  had  no  power  of  moving  even 
the  shoulders ;  the  pectoralis  major,  deltoid,  supra-  and  infra- 
spinatus, latissimus  dorsi,  and  subscapularis,  as  well  as  the  intrinsic 
muscles  of  the  upper  limb,  being  quite  flaccid  on  both  sides. 
There  was  no  tendency  to  rotation  of  the  humerus,  either  inwards 


INJURIES    TO    THE    CERVICAL    REGION.  '^^'J 

or  outwards.  On  the  other  hand,  the  trapezii  and  sterno-mastoids 
were  tonically  contracted. 

Respiration  was  diaphragmatic,  but  there  was  no  indication  of 
dyspnoea,  and  the  voice  was  not  weak.  The  urine  had  to  be 
drawn  off  by  means  of  the  catheter,  and  the  bowels  had  not  been 
moved  since  admission.  The  palpebral  fissures  were  smaller  than 
usual,  giving  the  patient  a  sleepy  look.  The  right  pupil  was 
as  described  above,  but  presented  some  further  contraction  on 
exposure  to  light. 

She  complained  of  a  sense  of  coldness  in  the  left  foot,  and  of 
great  pain  in  the  back  of  the  neck  and  across  the  shoulders,  pain 
being  aggravated  by  any  movement  of  the  shoulder-joint.  The 
limbs  and  trunk  were  completely  anaesthetic,  there  being  a  band 
of  hypersesthesia  about  i-|^  inches  wide  extending  across  the  chest 
in  the  form  of  a  collar,  at  the  level  of  the  second  ribs,  and  thence 
outwards  across  the  deltoids.  Above  this  line  sensation  was 
normal.  It  was  not  possible  accurately  to  define  the  limit  of 
sensibility  behind,  owing  to  the  necessary  movement  causing 
great  pain  in  the  neck.  The  firmly-contracted  trapezius  was 
painful  on  deep  pressure.  No  pain  was  caused  by  very  firm 
downward  pressure  on  the  head. 

The  plantar  reflex  was  exaggerated,  the  slightest  tickling  of 
the  soles  causing  clonic  spasms  of  the  limb.  No  abdominal 
cutaneous  reflex  could  be  obtained,  and  there  was  no  knee-jerk 
nor  ankle  clonus. 

The  cranial  nerves  presented  no  abnormality.  The  right  optic 
disc  was  normal ;  the  left  could  not  be  seen,  owing  to  a  com- 
mencing cataract. 

The  pulse  was  very  irregular  and  intermittent,  full,  soft,  and 
beating  at  the  rate  of  io8  per  minute.  The  heart-sounds  pre- 
sented nothing  abnormal. 

Respirations  were  28,  and,  as  above  stated,  entirely  diaphrag- 
matic, the  chest  falling  in  on  inspiration. 

The  temperature  at  8  a.m.  was  95°.  When  examined  at 
noon,  it  was  97°,  but  the  skin  of  the  trunk  and  lower  limbs  felt 
warm  and  somewhat  dry. 

The  urine  had  a  sp.  gr.  of  1024,  was  acid,  contained  no 
albumin  and  no  deposit.  It  decolorised,  but  did  not  precipitate 
Fehling's  solution.  The  nurse  afterwards  informed  me  that  there 
had  been  a  considerable  amount  of  vaginal  discharge.^ 

^  Xot  having  become  aware  of  the  condition  before  death,  I  am  unable  to  ascertain 
whether  the  discharge  was  of  leucorrhceal  or  other  natnre,  or  whether  it  may  have 
been  a  paralytic  secretion  from  the  vaginal  mucous  membrane. 


144382 


38  SURGERY    OF   THE    SPINAL    CORD. 

The  temperature  now  began  to  rise  steadily,  and  at  9  P.M.  on 
the  same  day  reached  101.6°,  at  which  it  remained  until  death, 
which  occurred  at  about  3  A.M.  on  the  following  day;  that  is, 
about  forty  hours  after  the  accident.  Death  resulted  from  failure 
of  respiration. 

At  the  post-mortem  examination  we  found  a  separation  between 
the  laminae  of  the  sixth  and  seventh  cervical  vertebra,  the  whole 
of  the  ligaments  uniting  the  arches  being  ruptured,  and  the  sixth 
vertebra  being  carried  forwards  and  to  the  right.  On  removing 
the  bones  en  masse,  the  left  inferior  articular  process  of  the  sixth 
was  found  completely  slipped  off  the  superior  articular  process  of 
the  seventh,  whereas  on  the  right  side  it  was  only  displaced 
forwards  to  a  slight  extent.  There  was  an  obliquely  horizontal 
fracture  across  the  body  of  the  seventh  vertebra,  extending 
from  the  cartilage  above  it,  forwards  and  slightly  downwards,  to 
a  line  about  one-fourth  of  the  distance  from  its  upper  to  its 
lower  border  in  front.  The  piece  of  bone  thus  separated  was, 
with  its  adjacent  cartilage  and  the  sixth  vertebra,  carried  for- 
wards and  somewhat  downwards  and  to  the  left.  On  opening 
the  spinal  canal,  there  was  found  extravasated  and  coagulated 
blood  external  to  the  dura  mater  throughout  the  entire  distance 
from  the  sixth  cervical  vertebra  to  the  inferior  termination  of  the 
canal.  The  disc  between  the  sixth  and  seventh  vertebrae  had 
been  crushed  and  forced  backwards  into  the  spinal  canal,  forming 
a  shelf  about  one  line  in  depth,  which  pressed  upon  the  cord,  but 
not  to  any  great  extent.  The  roots  of  the  seventh  nerves  were 
crushed.  The  cord  was  slightly  pressed  upon  by  the  above- 
mentioned  projecting  disc,  but  was  nowhere  compressed  by  the 
extra-meningeal  haemorrhage.  Opposite  the  body  of  the  sixth 
vertebra  it  presented  a  slight  swelling  of  a  bluish  colour,  its  sub- 
stance being  here  quite  diffluent  and  full  of  dark  blood.  From 
this  point  upwards  as  high  as  the  origin  of  the  third  cervical 
nerves  the  cord  was  very  soft,  and  contained  small  extravasations 
of  blood,  mainly  in  the  grey  matter,  and  especially  in  the  central 
canal,  these  appearances  being  less  marked  at  the  upper  than  at 
the  lower  part.  Below  the  sixth  intervertebral  disc  the  cord  was 
slightly  softened  for  the  distance  of  about  an  inch.  Elsewhere 
it  presented  no  abnormality  to  the  naked  eye.  The  membranes 
appeared  normal. 

In  this  case  no  information  of  value  is  to  be  obtained  as  to  the 
question  of  localisation,  for  the  haemorrhage  into  the  cord  extended 
so  rapidly  as  almost  at  once  to  paralyse  the  cord  throughout  the 


INJURIES    TO   THE    CERVICAL    REGION.  39 

entire  brachial  region,  although  the  lesion  of  the  vertebra  was  at 
the  level  of  exit  of  the  seventh  cervical  nerves.  For  a  short  time 
after  admission  the  nuclei  of  the  fifth  cervical  nerve  escaped  para- 
lysis on  the  right  side,  but  these  also  were  destroyed  before  I 
saw  the  patient,  and  death  soon  followed.  The  extensive  central 
haemorrhage  found  at  the  post-mortem  amply  explains  this  con- 
dition, and  the  case  is  chiefly  of  use  as  showing  that  the  damage 
to  the  cord  may  almost  at  once  extend  to  a  considerable  distance 
above  the  vertebral  lesion. 


Case  i  4. — Dislocation  of  seventh  cervical  vertebra — Haemorrhage 
extending  to  nuclei  for  triceps  muscles — Death. 

W.  T.,  aged  twenty-eight,  a  labourer,  was  admitted  to  the 
Manchester  Royal  Infirmary  under  the  care  of  Mr.  Wright  on 
October  3,  1887.  Two  days  previously  he  had  been  at  work  on 
the  roof  of  a  house,  when  he  fell  a  distance  of  about  eleven  feet  on 
to  a  block  of  stone,  which  struck  him  just  between  the  shoulder- 
blades,  causing  his  head  to  be  jerked  backwards.  He  felt  very 
sick,  but  did  not  vomit,  and  then  found  that  he  was  powerless  to 
move  either  his  arms  or  his  legs.  During  the  two  days  for  which 
he  remained  at  home,  no  change  can  be  ascertained  to  have  occurred 
in  his  condition. 

On  admission,  he  presented  complete  paralysis  of  the  lower 
limbs  and  of  the  abdominal  and  chest  muscles,  respiration  being 
diaphragmatic.  There  was  pain 
over  the  first  dorsal  vertebra, 
but  not  elsewhere,  and  no  pain 
on  pressing  down  the  head. 
The  upper  limbs  lay  across  the 
chest  with  the  elbows  close  to 
the  sides,  and  flexed,  as  in  the 
annexed  sketch,  made  by  the 
house-surgeon,  Mr.  Bannister. 
On  both  sides  the  flexors  of 
the  wrist  and  fingers  were  com- 
pletely paralysed,  and  he  had 
no  power  of  grasping ;  on  the 
right  side  the  extensors  were 
also  paralysed,  but  on  the  left 
they  retained  very  slight  power. 
The  triceps,  serratus  magnus,  and  pectoral  muscles  could  be  felt 
to  contract,  but  only  very  feebly  so.     The  biceps,  deltoid,   and 


Fig.  8.— Position  uccupioJ  l.y  ...^  l.;.....s  in  a  case 
of  complete  transverse  destruction  of  the  spinal 
cord  immediately  below  the  nuclei  for  the 
subscapularis  muscles. 


40  SURGERY    OF   THE   SPINAL    CORD. 

supinator  longus  were  more  powerful  than  any  of  the  other 
muscles  of  the  upper  limb,  but  were  also  weak. 

Ansesthesia  was  very  clearly  defined,  extending  over  the  lower 
limbs  and  up  the  trunk  as  high  as  the  level  of  the  second  rib  in 
front,  and  to  the  second  dorsal  spine  and  spines  of  the  scapulge 
behind.  In  the  upper  limbs  it  affected  the  little  finger  and  inner 
part  of  the  ring-finger,  the  ulnar  side  of  the  hand  and  forearm, 
and  the  intero-posterior  aspect  of  the  arm,  as  shown  in  the  shaded 
portions  of  the  sketch.  The  rest  of  the  upper  limbs  was  sensi- 
tive. About  the  boundary  of  the  aneesthetic  region  was  slight 
hypersesthesia,  more  marked  in  some  parts  than  in  others. 

Both  palpebral  fissures  and  pupils  were  small,  the  right  being 
more  markedly  so. 

The  bladder  was  much  distended,  and  on  passing  a  catheter  a 
large  amount  of  normal  urine  was  drawn  off. 

The  penis  was  semi-erect.     Temperature  99.8°. 

On  the  following  day  the  urine  was  ammoniacal,  and  of  a  deep 
purple  colour  from  admixture  of  blood.  This  profuse  haemorrhage 
from  the  kidneys  continued  for  some  days,  during  which  time  the 
patient  became  gradually  weaker,  but  it  ceased  on  the  eighth  day  ; 
the  urine  continuing,  however,  to  be  ammoniacal  and  containing 
some  pus. 

On  the  seventh  day  the  temperature  in  the  right  auditory  meatus 
was  found  to  be  101.2°  as  against  100.2°  on  the  left  side,  this 
observation  coinciding  with  the  more  marked  diminution  of  the 
pupil  and  palpebral  fissure  on  that  side,  due  to  paralysis  of  the 
sympathetic. 

On  October  20  the  optic  discs  were  examined  and  found  to  be 
normal. 

On  the  twenty-third  day  the  right  upper  limb  lay  across  the 
chest  with  the  elbow  to  the  side,  the  hand  on  the  upper  part  of 
the  sternum  and  the  fingers  closed.  When  asked  to  move  it,  the 
patient  only  rotated  the  humerus  outwards,  and  as  he  did  so  the 
supra-spinatus  and  infra-spinatus  could  be  felt  to  contract.  He 
still  had  very  feeble  power  of  flexing  the  elbow,  but  neither  the 
biceps  nor  the  supinator  longus  could  be  felt  to  contract,  and  he 
had  lost  all  power  over  the  deltoid.  All  the  other  muscles  of  the 
limbs  were  absolutely  paralysed.  On  the  left  side  the  elbow  was 
also  close  to  the  chest,  but  less  flexed,  so  that  the  forearm  was  at 
about  a  right  angle  to  the  upper  arm.  On  this  side  he  had  more 
power  of  flexing  the  elbow,  and  could  abduct  and  adduct  as  well 
as  rotate  the  shoulder,  there  being  obvious  contraction  of  the  del- 
toid, biceps,  and  spinati  muscles ;  he  had  also  some  feeble  power 


INJURIES    TO    THE  CERVICAL    REGION.  4 1 

of  pronation.  On  breathing  deeply,  the  levators  of  the  angles  of 
the  scapulae  could  be  felt  to  contract.  Anaesthesia  was  the  same 
as  on  admission. 

On  the  twenty -ninth  day  he  was  much  weaker,  and  it  was  found 
almost  impossible  to  draw  oif  the  urine,  owing  to  the  catheter  con- 
tinually becoming  blocked  with  stringy  mucus.  Severe  vomiting 
and  hiccough  also  troubled  him  greatly,  and  he  refused  all  food. 
The  temperature  throughout  the  case  varied  from  about  99°  to 
101°.  Two  days  later  he  died  exhausted,  having  survived  the 
accident  by  thirty-one  days. 

At  the  post-mortem  examination,  which  was  made  by  Dr. 
Harris,  there  was  found  rupture  of  the  disc  between  the  last  cer- 
vical and  first  dorsal  vertebrae,  the  parts  being  very  movable,  but 
no  fracture  was  detected,  and  when  the  post-mortem  was  made 
there  was  no  displacement.  The  cord  opposite  the  seat  of  injury 
was  almost  diffluent,  and  softening  extended  throughout  almost 
the  whole  cervical  region  and  for  some  short  distance  below,  but 
the  remainder  of  the  dorsal  region  showed  no  abnormality.  The 
bladder  was  much  enlarged  and  its  walls  thickened ;  on  its 
mucous  membrane  was  a  thick,  gritty,  yellowish-white  mem- 
brane, which  came  away  as  a  distinct  cast ;  the  peritoneal  surface 
was  inflamed  and  adherent  to  the  sigmoid  flexure  and  omentum. 
In  the  kidneys  were  the  appearances  of  acute  parenchymatous 
nephritis. 

Here,  as  in  Case  1 3 ,  we  find  the  cord-lesion  extending  above 
the  site  of  dislocation  before  the  patient  came  under  observation. 
As  before,  we  have  the  biceps,  deltoid,  and  supinator  fairly  power- 
ful. The  triceps,  serratus  magnus,  and  pectoral  muscles  also 
retain  a  fair  amount  of  power,  and  appear  to  have  received  about 
an  equal  amount  of  damage,  justifying  their  being  placed  near 
together  in  our  Table.  It  will  be  noticed  that  the  attitude  shown 
in  fig.  8  differs  from  that  of  fig.  i,  owing  to  the  adductors 
(chiefly  the  pectoralis  and  subscapularis)  of  the  humerus  not 
being  completely  paralysed.  At  the  end  of  three  weeks  we  find 
on  the  left  side  that  the  supra-spinatus,  infra-spin atus,  biceps, 
deltoid,  and  apparently  the  supinators,  subscapularis,  and  prona- 
tors retain  some  power ;  whereas  on  the  right  side  the  supra- 
spinatus  and  infra-spinatus  are  the  most  powerful  muscles,  and  the 
flexors  of  the  elbow  are  not  quite  paralysed,  as  are  the  remaining 
muscles.  Again,  therefore,  the  relative  strength  of  the  muscles 
confirms  the  arrangement  of  as  much  of  our  Table  as  is  here 
illustrated. 


42  SURGERY    OF   THE    SPINAL    CORD. 

We  have  thus,  by  comparing  these  fourteen  cases  of  fracture- 
dislocation  of  the  spine,  been  able  to  establish  on  a  fairly  secure 
basis  the  conclusions  set  forth  in  the  original  Table.  A  few  gaps 
and  a  few  discrepancies  remain,  but  considering  the  nature  of  the 
investigation,  these  do  not  appear  to  be  numerous  or  important. 
In  the  following  chapter  we  shall  find  not  only  a  confirmation  of 
our  results,  but  an  illustration  of  their  importance  for  the  purposes 
of  accurate  diagnosis. 

The  distribution  of  the  auaGsthesia  in  the  above  cases  is  of 
interest  equally  as  great  as  that  of  the  paralysis.  In  a  most 
interesting  and  important  paper,  Dr.  Ross  ^  has  fully  demonstrated 
the  nature  of  the  distribution  of  the  sensory  nerves  of  the  upper 
limb.  Regarding  the  limb  in  its  erabryological  position,  we  find 
that  it  is  projected  as  a  bud  from  the  trunk,  the  hand  being 
supine  and  the  radius  upwards,  with  the  palmar  surface  anterior. 
In  this  position  the  bud  carries  out  with  it  branches  of  the 
anterior  primary  divisions  of  the  spinal  segmental  nerves  from 
the  fifth  cervical  to  the  first  dorsal  inclusive ;  and  as  these 
nerves  maintain  their  embryological  relations  in  the  adult,  we 
have  the  several  roots  supplying  the  limb  in  numerical  order  from 
the  radial  to  the  ulnar  side.  Hence,  then,  the  higher  the  mischief 
extends  in  the  cord  through  the  brachial  region,  the  further  will 
the  anaesthesia  extend  from  the  ulnar  towards  the  radial  side. 
This  arrangement  is  fully  demonstrated  by  our  cases.  It  is 
unnecessary  to  refer  again  in  detail  to  this  distribution,  which 
will  be  obvious  upon  reading  the  reports.  It  will  be  found  that 
the  fifth  root  supplies  the  region  overlying  the  deltoid  muscle, 
and  the  outer  aspect  of  the  arm  and  forearm  as  far  as  the  styloid 
process  of  the  radius  or  base  of  the  thumb,  and  that  the  eighth 
cervical  and  first  dorsal  supply  the  little  finger  and  inner  side  of 
the  hand,  forearm  and  arm,  the  remaining  roots  providing  for 
the  central  parts  of  the  limb  on  both  anterior  and  posterior 
aspects.  The  exact  lateral  extent  of  the  bands  of  skin  thus 
supplied  by  each  root  can  hardly  be  determined,  and  is  indeed 
probably  not  a  fixed  quantity ;  the  boundaries  are  usually  ill- 
defined,  and  there  can  be  little  doubt  that  vicarious  conduction 
of  sensory  impressions  readily  arises,  as  in  other  varieties  of 
anaesthesia. 

1  The  Segmental  Distribution  of  Sensory  Nerves.     Brain,  January  1888. 


CHAPTER  11. 

INJURIES  TO  THE  CERVICAL  REGION  OP  THE 

SPINAL   CORD-Co^itinned. 

We  have  so  far  referred  only  to  cases  of  severe  crushing  of  the 
cord,  in  all  of  which  (except  Case  1 1 )  the  transverse  lesion  has 
been  complete,  and  has  entirely  annihilated  the  functions  of  the 
cord  below  its  level.  Moreover,  in  all  of  the  above  cases  the 
termination  has  been  death,  and  in  the  majority  a  post-mortem 
examination  has  confirmed  the  diagnosis  of  the  site  of  injury. 

We  pass  now  to  the  consideration  of  a  series  of  less  severe 
injuries,  which  will  best  illustrate  the  value  of  the  above  con- 
clusions for  purposes  of  localisation,  and  will  at  the  same  time 
serve  to  confirm  the  results  arrived  at. 


Case  i  5 . — Lateral  dislocation  of  fifth  cervical  vertebra — Injury  to 
left  fifth  cervical  nerve-root  and  hmmorrhage  into  cord  at  level 
of  origin  of  sixth  roots — Reduction — Recovery. 

E..  M.,  aged  fifty-five,  a  labourer,  was  admitted  to  the  Man- 
chester Royal  Infirmary  on  April  27,  1887,  under  the  care  of 
Mr.  Whitehead.  He  stated  that,  about  i  o  or  11  P.M.  on  the 
pi-evious  night,  he  had  fallen,  head  first,  down  some  seven  or 
eight  steps,  and  being  able  to  move  his  right  arm  only,  he  had 
remained  as  he  fell  until  7  a.m. 

On  admission  he  presented  the  following  symptoms : — The 
lower  limbs  appeared  to  be  quite  paralysed,  but  were  said  to  have 
been  moved  once  or  twice  during  the  morning ;  they  were  very 
rigid ;  the  knee-jerks  were  much  exaggerated,  and  the  cremas- 
teric reflexes  absent.  On  respiration  costal  movement  was  slight, 
but  quite  distinct.  Anaesthesia  extended  as  high  on  the  trunk 
as  I  the   level   of  the    second  ribs,   but  was   not  quite    complete. 


44  SURGERY    OF    THE    SPINAL    CORD. 

Urine  was  retained  ;  the  penis  was  not  turgid.  The  condition  of 
the  upper  limbs  was  more  interesting.  The  left  was  completely 
paralysed,  lying  by  the  side.  The  right  was  abducted  at  the 
shoulder,  with  the  elbow  strongly  flexed,  so  that  the  hand  lay 
above  the  shoulder  with  the  palm  backwards,  i.e.,  in  a  state  of 
supination,  the  lingers  and  wrist  being  slightly  flexed.  He  could 
raise  and  rotate  the  shoulders,  but  had  no  other  power  of  move- 
ment in  the  limb.  There  was  almost  absolute  anaesthesia  of  the 
left  upper  limb,  but  on  the  right  side  loss  of  sensation  was 
limited  to  the  ulnar  aspect.  Both  pupils  and  palpebral  fissures 
were  small.  The  head  and  neck  were  markedly  bent  to  the 
right,  and  there  was  a  distinctly-felt  lateral  curvature  in  the  cer- 
vical region. 

Having  concluded  that  there  was  a  dislocation,  probably 
unilateral,  of  the  fifth  cervical  vertebra,  and  having  in  view  the 
otherwise  inevitably  fatal  termination  of  the  case,  we  resolved  to 
attempt  immediate  reduction.  This  was  performed  as  follows  : — 
The  man  lying  on  his  back  in  bed,  I  seized  him  firmly  by  the 
shoulders,  and  Mr.  Collier,  then  resident  surgical  officer,  grasping 
the  head,  drew  it  upwards  and  to  the  right,  then  bringing  it 
over  to  the  left.  A  slight  snap  was  felt,  and  the  position  of  the 
head  was  rendered  more  nearly,  but  not  yet  quite  straight.  The 
same  proceeding  being  repeated,  a  snap  was  again  felt,  and  the 
head  came  into  its  normal  position.  At  this  movement  the  patient 
screamed  with  pain  shooting  down  the  left  arm,  and  situated,  he 
said,  on  the  side  further  from  the  thumb.  This  pain  lasted  only 
for  a  minute  or  two.  Within  half-a-minute  he  flexed  the  left 
elbow,  and  then  again  kept  the  limb  quiet  with  the  elbow  flexed. 
On  re-examining  the  sensation  of  the  left  upper  limb,  we  found 
partial  sensibility  on  the  ulnar  side,  but  the  radial  side  remained 
anaesthetic  as  before.  At  the  same  time  we  noticed  a  diffused 
swelling  in  the  left  posterior  triangle  of  the  neck,  due  doubtless 
to  effused  blood,  which  subsided  in  a  few  days  without  giving  any 
trouble.  Finally,  we  adapted  to  the  patient's  head,  neck,  and 
shoulders  a  felt  casing,  designed  to  keep  them  in  position.  No 
deformity  of  the  head  or  neck  remained.  At  2  P.M. — an  hour 
later — the  patient  could  move  the  elbow  and  fingers  on  the  left 
side,  and  sensation,  as  before,  was  absent  only  on  the  radial  aspect 
of  the  limb.  There  was  no  marked  rise  of  temperature  either 
now  or  at  any  subsequent  period  in  the  course  of  the  case. 

On  the  following  day  a  large  amount  of  urine  was  passed,  and 
the  catheter  was  not  required  after  this  date.  The  urine  had  a 
sp.  gr.  of  1024,  contained  a  large  quantity  of  urates,  with  some 


INJUKIES    TO    THE    CERVICAL    REGION.  45 

albumin,  and  decolorised  Fehling's  solution  without  giving  a  pre- 
cipitate. The  penis  was  slightly  turgid.  There  was  a  good  deal 
of  pain  between  the  shoulders,  but  no  other  change. 

On  April  29,  the  third  day,  sensation  was  more  acute  in  the 
lower  limbs,  especially  on  the  right  side,  and  in  the  angesthetic 
portions  of  the  upper  limbs.  The  patellar  reflexes  were  less 
exaggerated  than  before,  and  the  limbs  less  rigid.  The  right 
upper  limb  presented,  as  before,  the  symptoms  of  complete  para- 
lysis of  motion  and  sensation  below  the  distribution  of  the  fifth 
cervical  root ;  on  the  left  side  the  fingers,  wrist,  and  elbow  could 
be  feebly  flexed  and  extended  ;  the  wrist  could  be  pronated  and 
supinated,  and  the  humerus  slightly  abducted  and  adducted.  The 
urine  was  now  alkaline,  very  foetid,  and  contained  pus.  The  optic 
discs  were  normal.  A  day  later  the  patient  had  more  power  in 
the  left  upper  limb,  and  anaesthesia  was  nowhere  complete.  On  the 
right  side  he  had  gained  some  power  of  pronating  the  wrist  and 
of  extending  the  elbow, 
and  the  area  of  sensation 
was  extending.  The  knee- 
jerks  were  about  normal ; 
the  contraction  of  the 
pupils  less  marked.  The 
annexed  illustration  (fig. 
9),  taken  from  a  photo- 
graph obtained  for  me  by 
Mr.  Sidley  at  about  this 

.     -1       I  ,,  ...  Fig.  9. — From  a  photograph  of  Case  15,  sliowingtlie  posi- 

periOd,   snows  the  position  tlon  of  the  limbs  where  the  fifth  cervical  nerve-root 

(.  ,,       ^^      ^  T    •     T       ,  was  injured  on  the  left  side  onlv. 

01  the  limbs,  and  indicates 

the  marked  abduction  of  the  humerus  and  flexion   of  the  elbow 

on  the  right  side. 

From  this  point  it  is  unnecessary  to  give  a  daily  record,  and 
it  will  suffice  to  note  merely  a  few  of  the  more  important  changes. 
Sensation  very  gradually  returned  throughout,  being  preceded,  as 
usual,  by  a  sense  of  tingling  in  the  limbs  ;  the  right  lower  limb 
recovered  more  quickly  than  the  left.  Traces  of  albumin  and 
sugar  (?)  disappeared  from  the  urine  within  a  week,  as  did  the 
pus  and  the  alkaline  reaction.  For  a  long  time  there  was  some 
difficulty  in  passing  urine,  but  this  gradually  passed  off.  The 
pupils  returned  to  their  normal  condition  in  about  a  month,  the 
right  doing  so  the  more  slowly,  and  even  as  lately  as  January 
1888  being  smaller  than  the  left.  The  knee-jerks  had  quite 
disappeared  by  May  5,  and,  after  being  absent  for  some  time, 
gradually  returned  in  the  exaggerated  form   of  spastic  paralysis. 


46  SURGERY    OF   THE    SPINAL    CORD. 

whicli  they  still  retain,  and  which  is  more  marked  on  the  right 
side.  On  May  1 1  the  patient  could  move  the  lower  limbs  about 
the  bed  very  fairly.  In  about  six  months  he  could  walk.  In  the 
upper  limbs  return  of  power  was  equally  slow,  and  there  is  here 
a  good  deal  of  atrophy,  this  atrophy  and  weakness  being  even  now 
more  marked  on  the  right  than  on  the  left  side.  In  August  all 
the  muscles  of  the  left  upper  limb  reacted  well  to  the  faradic 
current,  whereas  on  the  right  side  only  the  biceps,  deltoid,  and 
supinator  longus  did  so,  so  that  on  that  side  the  "  reaction  of 
degeneration  "  was  present  below  the  fifth  root.  After  the  accident 
the  nails  of  both  hands  grew  in  a  markedly  clubbed  form. 

Since  he  left  the  Infirmary  this  man  has  frequently  reported 
himself  to  me,  and  when  I  last  saw  him,  in  August  1888,  he 
could  walk  well,  but  with  the  usual  spastic  gait,  and  complained 
only  of  a  feeling  of  numbness  in  the  lower  limbs,  abdomen,  and 
hands.  His  upper  limbs  are  a  good  deal  wasted,  but  he  has  very 
fair  power  throughout,  and  can  do  light  work,  having  no  difficulty 
even  in  such  movements  as  are  required  for  lacing  his  boots  or 
buttoning  his  clothes. 

In  this  case  I  think  we  may  assume  that  there  was  a  disloca- 
tion of  the  fifth  cervical  vertebra,  and  that  the  traction  thereby 
caused  had  injured  the  left  fifth  cervical  nerve-roots  at  their  point 
of  exit  from  the  spinal  canal,  so  as  to  completely  paralyse  sensation 
and  motion  in  the  distribution  of  that  nerve,  but  that  the  cord  itself 
was  not  completely  crushed,  having  only  sustained  haemorrhages 
into  its  substance  of  slight  extent  as  compared  with  those  in  the 
cases  reported  in  the  last  chapter.  As  shown  in  the  accompany- 
ing diagram  (fig.  10),  the  right  fifth  cervical  root  would  escape 
— the  cord  below  this  region  would  be  affected  by  partial  destruc- 
tion (which  was  more  complete  on  the  right  side) — and  the  left 
fifth  cervical  root  would,  as  already  stated,  be  partially  torn  or 
greatly  stretched,  so  as  to  suffer  temporary  total  paralysis. 

Hence,  we  have  on  the  right  side  partial  paralysis  of  the  upper 
limb,  the  biceps,  deltoid,  and  supinator  longus  escaping  as  in 
other  cases  in  which  the  fifth  root  is  spared,  together  with  re- 
tention of  sensation  on  the  outer  side  of  the  limb  supplied  by 
the  same  nerve.  All  sensation  is  lost  below  this  root,  and  the 
pupil  is  smaller  in  size  upon  this  side  of  the  body  than  on  the 
other,  coinciding  with  the  greater  amount  of  damage  done  to 
the  cord.  This  is  also  evidenced  by  the  fact  that  anaesthesia 
was  more  marked  on  the  left  than  on  the  right  side  in  the 
lower  part  of  the  body,  and  that  the  paralysis  of  those  muscles 


INJURIES    TO    THE    CERVICAL    REGION. 


47 


of  the  upper  limb  supplied  from  below  the  fifth  root  was  more 
marked  on  the  right  side,  as  was  the  exaggeration  of  the  tendon 
reflexes.  On  the  right  side,  also,  we  have  the  "  reaction  of  dege- 
neration "  resulting,  whereas  on  the  left  it  did  not  do  so.  On  the 
left  side,  on  the  other  hand,  we  find  that  the  movements  of  re- 
duction, by  irritating  the  over-stretched  fifth  root,  caused  some  of 
the  muscles  supplied  by  it  to  contract  during  the  manipulation, 
but   that  both   motor  and   sensory  paralysis  were  more  marked 


5'"  Cervical  Vertebra   Dislocateb 

Left  5^"   Root  Torn 

-Region     of    Crush  of    CoRe 
6'^"    Cervical    Vertebra 


Pig.  io. — Diagram  of  the  supposed  nature  of  the  lesion  in  the  case  of  R.  M.    The  left  fifth  cervical 
nerve-root  should  appear  as  crushed  or  stretched  rather  than  completely  torn. 

and  enduring  in  this  root  than  elsewhere.  The  vesical  and  other 
symptoms  are  compatible  with  a  partial  destruction  of  the  cord, 
and  passed  off  to  a  large  extent  as  repair  ensued.  One  point 
in  this  case  is  quite  unusual,  namely,  the  early  exaggeration  of 
the  patellar  reflexes,  these  being  as  a  rule  lost,  owing  to  the 
shock  of  the  injury;  whereas  here,  as  in  Case  ii,  they  were 
increased,  probably  owing  to  irritation  ;  as  the  irritation  subsided 
they  disappeared,  and  then  at  a  later  stage  reappeared  in  an 
exaggerated  form — the  usual  result  of  an  old  transverse  lesion. 

We  may  now  refer  to  five  cases  of  haematomyelia  unaccompanied 
by  any  severe  lesion  of  the  vertebral  column,  which  present 
numerous  interesting  points. 


Case  i6. — Traumatic  hcematomyelia  in  lower  cervical  and  upper 
do7'sal  region — Death. 

J.  B.,  aged  thirty-four  years,  suffering  from   an  injury  to  the 
spine,  was  admitted  on  December  30,  1885,  under  the  care  of 


48  SURGERY    OF   THE    SPINAL  CORD. 

Mr.  Heath.  He  was  a  carter  by  occupation,  and  was  hurt  while 
loading  a  waggon  by  a  "  tippler  "  full  of  coal  falling  upon  him  so 
as  to  throw  him  upon  his  face,  the  coal  striking  him  between  the 
shoulders. 

On  admission  to  the  Infirmary  he  was  quite  conscious,  but 
stated  that  he  had  been  rendered  insensible  for  some  time  by  the 
injury.  He  had  complete  loss  of  power  over  both  lower  extremi- 
ties, and  complained  of  great  pain  at  the  back  of  the  neck  and 
between  the  shoulders,  which  was  increased  by  moving  the  head. 
He  had  also  pain  from  a  severe  bruise  over  the  right  elbow.  On 
the  left  side  of  the  head  were  three  slight  scalp-wounds. 

A  more  careful  examination  showed  him  to  have  pain,  increased 
by  pressure,,  mainly  over  the  fifth  and  sixth  cervical  vertebrse  ; 
but  no  irregularity  was  here  detected  in  the  spine.  There  was 
absolute  paralysis  of  both  lower  extremities,  with  deficient  action 
of  the  intercostal  and  anterior  abdominal  muscles  in  respiration, 
but  good  movement  of  the  diaphragm.  Both  legs  were  completely 
anaesthetic  as  high  as  the  knees  ;  but  thence  upwards  he  had  some 
sensation,  although  there  was  distinct  numbness  as  high  as  a  line 
drawn  round  the  abdomen  about  two  inches  below  the  umbilicus. 
There  was  no  hyperaesthesia.  The  plantar  reflexes  were  noted  as 
"  almost  absent,"  and  the  feet  felt  very  cold,  with  some  prickling 
sensation.  He  had  distinct  priapism.  Both  pupils  were  much 
contracted,  but  equal,  and  contracting  further  on  exposure  to  light. 
There  was  no  vomiting  and  no  mental  affection.  He  was  placed 
on  a  water-bed,  the  scalp-wounds  dressed,  and  ext.  ergot,  liq. 
administered  in  3ss  doses.  In  the  evening  the  urine  had  to  be 
withdrawn. 

On  the  following  day  there  Avas  still  absolute  paralysis  of  the 
lower  limbs,  but  there  was  now  no  aneesthesia.  The  priapism 
had  subsided,  and  the  urine  was  passed  without  any  trouble.  The 
diaphragmatic  respiration  was  very  marked.  On  examining  the 
arms,  which  had  not  been  done  the  day  before,  I  found  marked 
weakness  of  the  flexors  of  the  wrist  and  fingers  on  both  sides ; 
the  grip  was  very  feeble,  but  the  power  of  extension  against  re- 
sistance was  little  if  at  all  diminished.  The  superficial  reflexes 
and  tendon  reactions  were  everywhere  absent.  The  left  pupil  was 
somewhat  contracted,  but  the  right  one  very  much  more  so  ;  both 
contracted  further  on  exposure  to  light.  The  patient  had  some 
vomiting  during  the  night,  and  there  were  rales  all  over  the  chest. 
The  temperature  was  98.6°  F.  in  the  morning,  and  99.8°  F,  in 
the  evening. 

On    the    following  day,    January    i,    1886,  the  faeces   were 


INJURIES   TO    THE    CERVICAL   REGION.  49 

passed  involuntarily.  There  was  severe  and  painful  cough,  and 
all  over  the  chest  loud  crackling  rales ;  the  countenance  was 
cyanotic.  No  other  change  had  occurred.  Temp.,  morning  99°; 
evening,  100°.  The  cyanosis  and  difficulty  of  breathing  now 
rapidly  increased,  and  there  was  dulness  at  the  bases  of  both 
lungs,  but  no  crepitations  were  heard.  Without  further  symp- 
toms, the  man  died  on  the  night  of  January  2,  1886. 

The  post-mortem  examination  revealed  engorgement  of.  the 
bases  of  both  lungs  and  of  the  right  side  of  the  heart ;  but  the 
other  organs  were  healthy,  with  the  exception  of  the  spinal  region. 
In  the  muscles  over  the  lower  cervical  and  upper  dorsal  regions 
was  some  dark  effused  blood,  but  the  vertebral  column  presented 
no  evidence  of  injury.  The  membranes  of  the  cord  were  quite 
normal,  as  was  the  external  appearance  of  the  cord  itself;  but 
"  on  section  there  was  found  to  be  a  dark  black  hasmorrhage 
into  the  central  grey  matter  in  the  lower  cervical  and  upper 
dorsal  regions.  This  haemorrhage,  which  measured  in  its  vertical 
extent  from  i-^  to  2  inches,  was  in  the  greater  part  of  its  extent 
situated  centrally,  occupying  the  whole  of  the  central  grey  matter 
and  extending  but  little  into  the  white  substance,  which  in  its 
neighbourhood  was  merely  softened  and  of  a  faintly  yellow  tinge. 
At  the  lower  part,  for  a  very  short  distance,  the  haemorrhage  was 
limited  to  the  anterior  cornu  of  the  right  side,  while  thei  corre- 
sponding left  horn  appeared  to  be  perfectly  healthy.  Elsewhere 
the  cord  was  firm,  and  presented  no  abnormality." 

In  this  case  the  haemorrhage  extended  only  into  the  nuclei  of 
the  nerves  to  the  flexors  of  t]jp ''wrist  and  fingers,  leaving  intact 
those  supplying  the  muscles  which,  in  our  Table,  have  been  placed 
on  a  higher  level. 

Case  17. — HcBinatomyelia  in  middle  cervical  region — Eecovery. 

J.  A.,  a  bailiff,  aged  sixty-two,  attended  as  an  out-patient 
under  the  care  of  Dr.  Eoss  in  December  1886.  He  told  us 
that  nine  weeks  previously  he  had  fallen  about  nine  or  ten 
feet,  and,  having  held  out  his  arms  to  save  himself,  came  down 
upon  his  hands.  For  a  second  or  two  he  felt  nothing,  but  had 
then  great  pain  shooting  down  the  arms  to  the  hands.  His 
upper  limbs  rapidly  became  spasmodically  contracted,  so  that  he 
held  them  with  the  elbows  to  the  sides  and  flexed,  the  hands  in 
front  and  partially  flexed — i.e.,  as  he  showed  us,  very  much  in 
the  position  in  which  a  book  might  be  held   for  reading.     This 

D 


50  SUKGERY    OF   THE   SPINAL    CORD. 

pain  and  spasm  lasted  for  about  a  fortnight,  since  which  time 
they  had  been  gradually  abating,  and  when  he  came  to  the 
Infirmary  he  had  not  much  pain,  and  could  move  the  arms  in 
all  directions,  although  they  were  still  weak  and  he  could  not 
well  throw  them  backwards.  The  legs  had  felt  cold  and  weak 
since  the  accident 

On  examination,  we  found  hyperaesthesia,  cutaneous  and  deep, 
extending  across  the  shoulders  from  the  sixth  or  seventh  cervical 
spine  to  the  acromia.  He  had  no  spinal  pain  or  tenderness.  On 
carrying  the  arms  backwards  there  was  pain  which  prevented 
his  dressing  himself.  He  had  no  trace  of  anaesthesia.  Over  the 
hyperassthetic  region  was  a  slight  vesicular  eruption.  All  the 
arm-muscles  appeared  to  be  fairly  strong.  The  lower  limbs  felt 
weak,  and  the  knee-jerk  was  increased.  There  were  no  urinary 
troubles. 

On  January  i8,  1887,  I  again  examined  him  more  carefully. 
No  local  signs  of  spinal  injury  could  be  detected.  The  upper 
level  of  the  hyperaesthetic  band  was  on  a  level  with  the  sixth 
cervical  spinous  process,  and  the  lower  some  -two  inches  further 
down ;  the  band  extended  outwards  on  either  side  for  about  three 
inches,  i.e.,  as  far  as  to  the  distribution  of  the  descending  branches 
of  the  cervical  plexus.  Its  boundaries  were  well  marked,  espe- 
cially above.  The  vesicular  eruption  had  almost  disappeared,  and 
appeared  on  inquiry  to  have  been  due  to  previous  friction  with 
acetic  acid. 

All  the  muscles  of  the  upper  limbs  presented  a  fair  amount  of 
power,  but  the  deltoid  and  biceps  appeared  to  be  relatively  the 
strongest  muscles  and  the  retractors  of  the  humerus  (latissimus 
dorsi)  the  feeblest.  The  hands  and  flexors  of  the  wrists  were 
wasted  to  some  extent.  All  the  muscles  reacted  to  moderately 
powerful  faradic  currents.  No  sensory  change  could  be  made 
out  in  the  upper  limbs,  and  there  was  no  jerk  on  striking  the 
triceps  or  wrist  tendons. 

Examined  in  a  dim  light,  the  pupils  were  distinctly  smaller 
than  norpial,  the  change  being  more  marked  on  the  right  side, 
and  they  did  not  dilate  on  pinching  the  neck.  The  legs  were 
well  developed,  and  presented  no  paralysis,  anaesthesia,  or  trophic 
lesions ;  but  the  patient  stated  that  they  did  not  feel  so  strong 
as  formerly,  and  were  always  either  cold  or  burning  hot.  The 
knee-jerks  were  markedly  exaggerated ;  the  superficial  reflexes 
absent.     The  bladder  and  rectum  presented  no  abnormality. 

I  saw  this  patient  again  on  April  28,  1888,  when  he  told  me 
that  he  was  much  better  than  he  had  been  at  first,  but  that  he 


INJURIES    TO   THE    CERVICAL   REGION.  5 1 

still  felt  some  feebleness  of  both  arms  and  legs,  and  that  occasion- 
ally the  legs  felt  hot  or  cold.  He  presented  no  very  marked 
signs  of  injury,  being  quite  able  to  go  about  and  perform  all  the 
usual  muscular  movements.  His  arms  were,  however,  not  very 
strong,  and  there  was  obvious  wasting  of  both  triceps  muscles. 
On  making  an  electrical  examination,  I  found  that  the  flexors  of 
the  wrist  required  a  more  powerful  faradic  current  than  the 
biceps,  the  extensors  of  the  wrist  a  still  more  powerful  one,  and 
the  triceps  could  only  be  got  to  contract  with  very  strong  faradic 
currents.  With  the  galvanic  current,  cathodal  closure  in  every 
muscle  caused  contractions  more  readily  than  anodal  closure,  so 
that  there  was  no  reaction  of  degeneration.  Hence  the  muscles 
of  the  upper  limb  were  partially  atrophied  and  insensitive  to  the 
faradic  current  in  varying  degrees,  the  most  active  being  the 
biceps,  then  the  flexors  of  the  wrist,  then  the  extensors,  and  the 
weakest  being  the  triceps.  The  knee-jerks  were  slightly,  but  not 
much  exaggerated.  He  had  no  pain,  anaesthesia,  hypersesthesia, 
or  cutaneous  eruption. 

This  case  would  appear  to  be  another  example  of  haemorrhage 
into  the  central  grey  matter  of  the  spinal  cord,  most  severe  in 
the  neighbourhood  of  the  triceps  and  latissimus  nuclei,  but  extend- 
ing into  those  immediately  above  and  below.  The  flexOrs  of  the 
elbow  and  the  shoulder  muscles  escaped  entirely  the  destroying 
lesion,  but  irritation  caused  the  spasmodic  position  of  the  limbs 
which  he  at  first  experienced  ;  similarly,  there  was  spasm  below 
the  region  of  the  haemorrhage,  causing  flexion  of  the  fingers  and 
wrist.  Hence  we  have  spasm  in  two  groups  of  muscles — those 
above  and  those  below  the  lesion,  viz.,  above,  the  biceps,  subscapu- 
laris,  and  others,  causing  the  humeri  to  assume  a  position  similar  to 
that  shown  in  fig.  8  ;  and  below,  the  flexors  of  the  hand  and  fingers. 
At  the  stage  when  we  saw  the  man,  this  spasm  had  passed  away ; 
the  paralytic  symptoms  were  most  prominent,  aSecting  the  central 
group  of  muscles — the  triceps  and  retractor  muscles  (latissimus 
and  teres  major),  and  to  a  rather  less  extent  the  extensors  of  the 
wrist  and  fingers.  The  region  of  hyperaesthesia  corresponded  to 
the  posterior  divisions  of  the  central  nerves  of  the  plexus.  It  is 
remarkable  that  there  was  no  sensory  affection  in  the  distribution 
of  the  anterior  divisions,  i.e.,  in  the  central  part  of  the  arms,  but, 
as  stated  on  p.  42,  I  am  inclined,  from  various  observations,  to 
believe  that  the  central  nerves  of  the  brachial  plexus  have  a 
comparatively  narrow  area  of  distribution  in  the  upper  limbs,  and 
doubtless  the  anterior  and  posterior  bands  which  they  do  supply 


52  SUEGERY    OF    THE   SPINAL   CORD. 

would  shortly  be  vicariously  supplied  by  the  upper  and  lower 
branches  on  either  side  of  them.  The  diagnosis  of  a  central 
haemorrhage  rather  than  a  meningeal  lesion  must  rest  chiefly  on 
the  rapid  onset  of  the  symptoms.  Meningitis  could  not  cause 
symptoms  within  a  few  minutes,  and  a  meningeal  haemorrhage 
would  be  less  distinctly  localised. 


Case  i8. — HcematoTtiyelia  in  the  region  of  tlie  triceps  nucleus. 

R.  P.,  aged  twenty-five,  a  porter,  was  admitted  to  the  Man- 
chester Royal  Infirmary  under  Mr.  Hardie's  care  on  December 
19,  1887.  He  had  on  the  same  day  been  walking  along  the 
streets,  which  were  slippery,  when  he  fell  at  full  length  on  his 
back.  He  was  seized  with  a  sudden  pain  at  the  lower  part  of 
the  neck,  shooting  down  the  arms,  and  at  once  sustained'  com- 
plete loss  of  power  in  his  legs  and  partial  loss  in  his  arms.  He 
was  never  unconscious. 

When  examined,  he  presented  severe  pain  in  the  lower  cervical 
region,  shooting  thence  down  the  arms.  No  deformity  of  the 
spine  could  be  felt,  but  pressure  caused  great  pain  between '  the 
fourth  cervical  and  first  dorsal  vertebrae,  and  pain  was  caused  by 
pressing  the  head  downwards  or  moving  it  from  side  to  side.  He 
lay  in  bed  with  the  forearms  folded  across  the  chest,  the  elbows 
being  a  little  abducted,  the  hands  prone  ;  abduction  and  adduc- 
tion of  the  humerus  were,  however,  fairly  well  performed,  as  were 
pronation  and  supination.  Flexion  of  the  forearm  was  not  much 
impeded,  but  the  power  of  extension  was  lost.  The  grasp  of  the 
hand  was  exceedingly  feeble,  and  extension  at  the  wrist  resulted 
from  the  effort.  The  flexors  and  extensors  of  the  wrist  were 
weakened,  apparently  about  equally  so.  The  intrinsic  muscles 
of  the  hands  were  very  feeble.  These  symptoms  were  similar 
on  both  sides,  except  that  on  the  right  adduction  of  the  humerus 
was  less  powerful  than  on  the  left,  whereas  the  grasp  of  the  hand 
was  stronger  on  the  right  side,  and  unaccompanied  by  extension 
at  the  wrist.  On  the  left  side  sensation  was  thought  to  be  some- 
what deficient  in  the  fingers,  but  there  was  no  other  affection  ;  on 
the  right  side  it  was  normal. 

The  chest-movements  were  feeble,  and  the  legs  showed  great 
loss  of  power,  but  sensation  was  unaffected.  The  knee-jerk  and 
plantar  reflexes  were  exaggerated  on  both  sides.  He  had  no 
bladder  or  rectal  troubles;  the  urine  was  of  sp.  gr.  1019,  acid, 
containing   a  trace   of  albumin,   but  no   sugar.       Temperature, 


INJUEIES    TO    THE   CERVICAL   REGION.  53 

100.6°;  pulse  80.  Ext.  ergot,  liq.  was  administered  several 
times. 

Two  days  later  the  arms  were  slightly  stronger,  the  legs  de- 
cidedly so  ;  the  temperature  had  fallen,  and  shortly  reached  the 
normal. 

On  December  27  extension  of  the  forearms  was  still  weak,  but 
the  other  movements  much  better.  He  had  now  ceased  to  retain 
the  fixed  position  described  above,  except  at  times,  and  had  hardly 
any  pain.  Improvement  was  rapid,  and  on  January  16,  1888, 
he  was  discharged  cured,  except  for  some  slight  feebleness  of  the 
grasp. 

The  above  account  is  taken  from  notes  by  Mr.  Bannister,  the 
house-surgeon,  as  I  only  saw  the  case  a  few  days  before  his 
discharge. 

This  is  another  instance  of  a  small  haemorrhage,  mainly  in 
the  region  of  the  triceps  nucleus — a  haemorrhage  confined  to  the 
anterior  cornua,  and  afiecting  only  the  motor  apparatus.  It  is 
needless  to  repeat  the  evidence,  which  shows  that  it  was  most 
severe  in  the  region  of  the  triceps  nucleus,  but  extended  thence 
to  those  of  the  extensors  and  flexors  of  the  fingers,  and  that  it 
was  at  a  rather  higher  level  on  the  right  than  on  the  left  side, 
so  that  on  the  former  the  adductors  of  the  humerus  were  also 
weakened. 


Case  19. — Hcematomyelia  in  middle  cervical  region — Eecovery 
with  persistent  symptoms. 

W.  H.,  aged  thirty- six,  a  carter,  was  admitted  under  the  care 
of  Mr.  Hardie  on  June  13,  1885.  About  half-an-hour  before 
admission  he  had  fallen  between  the  shafts  of  a  van  which  he 
was  driving,  and  one  wheel  had  passed  over  his  shoulders. 

On  admission,  he  lay  quite  helpless,  there  being  complete 
paralysis  of  the  left  arm  and  of  bath  legs,  while  the  right  arm 
was  partially  paralysed,  but  retained  some  motor  power,  "  espe- 
cially at  the  elbow."  Respiration  was  diaphragmatic.  The 
reflexes  were  normal.  There  was  anaesthesia  below  the  dis- 
tribution of  the  cervical  nerves.  Speech  was  laboured,  owing  to 
difficulty  in  breathing,  but  there  was  no  loss  of  consciousness 
or  mental  confusion.  The  left  pupil  and  palpebral  fissure  were 
slightly  smaller  than  those  of  the  right  side.  There  was  much 
pain  in  the  back  of  the  neck,  but  no  abnormality  was  there 
detected.     After -the  patient  had  been  put  to  bed,  he  was  able  to 


54  SUEGERY    OF   THE   SPINAL   CORD. 

move  the  right  lower  extremity  slightly.  There  was  great'  thirst 
and  dryness  of  the  mouth.  The  urine  had  to  be  drawn  off;  it 
was  acid,  of  a  specific  gravity  of  loio,  and  contained  neither 
sugar  nor  albumin.  He  was  placed  on  a  water-bed,  the  head 
being  fixed  by  sandbags. 

On  the  following  morning  it  was  ascertained  that  sensation 
was  nowhere  absolutely  lost,  but  that  it  was  impaired  on  both 
sides  of  the  body,  more  markedly  on  the  right  than  on  the  left. 
There  was  more  power  of  moving  the  right  leg  and  arm  ;  the 
limbs  of  the  left  side  remained  completely  paralysed.  Other 
symptoms  continued  as  before ;  the  temperature  was  in  the 
morning  ioo.2°,  in  the  evening  ioi°.  There  was  free  perspira- 
tion ;   the  urine  was  scanty  and  high-coloured. 

When  examined  on  June  1 5 ,  forty-eight  hours  after  the 
accident,  the  shock  had  passed  off",  and  there  was  less  pain  in  the 
neck.  The  right  arm  and  leg  were  more  powerful,  and  the 
rhomboids,  posterior  scapular  muscles,  biceps,  deltoid,  and  supina- 
tor longus  acted  well,  although  the  other  muscles  of  this  limb 
were  paralysed.  The  left  arm  and  leg  remained  completely 
paralysed.  Sensation  was  returning  on  both  sides,  but  remained 
less  acute  on  the.  right  than  on  the  left  side.  This  diminution 
of  sensation  extended  as  high  as  the  supra- clavicular  branches  of 
the  cervical  plexus.  The  reflexes  were  normal.  There  appeared 
to  be  some  slight  movement  of  the  intercostal  muscles  in 
respiration.  The  pulse  was  beating  at  the  rate  of  102;  the 
temperature  was  in  the  morning  102°,  in  the  evening  102.4°. 

On  the  following  day  there  was  further  gain  of  sensation  and 
of  power  on  the  right  side.  On  the  left  side  were  slight  prick- 
ing sensations.  The  temperature  had  fallen  to  99.4°.  Other 
symptoms  were  as  before.  It  was  noted  that  there  had  through- 
out been  no  priapism. 

On  June  17  he  passed  his  urine  without  the  use  of  a 
catheter,  and  had  no  further  trouble  with  it.  His  bowels  were 
now  opened  for  the  first  time  since  the  accident.  The  pulse 
remained  somewhat  rapid,  being  85  in  the  morning,  and  100  in 
the  evening;  the  temperature  was  ibi°.  On  the  19th  there 
was  distinct  costal  respiratory  movement.  The  pulse  was  still 
rapid,  and  the  temperature  100°.  On  the  26th  the  temperature 
for  the  first  time  reached  the  normal,  at  which  it  afterwards 
remained,  except  temporarily  on  two  unexplained  occasions. 

On  June  24  there  seemed  to  be  little  or  no  further  change, 
and  iodide  of  potassium  was  ordered  in  gr.  x.  doses.  From 
this  point  improvement  progressed  very  slowly.      On  July  4th 


INJURIES    TO    THE    CERVICAL    REGION.  55 

he  was  able  to  move  both  shoulders  very  slightly,  and  the 
intercostal  muscles  acted  more  freely  on  the  right  than  on  the 
left  side ;  there  was  no  other  change  in  the  paralysis.  The 
knee-jerk  was  exaggerated  on  both  sides ;  there  was  no  ankle- 
clonus.  On  July  20th  he  was  transferred  to  the  medical  wards, 
under  the  care  of  Dr.  Ross,  where  very  full  notes  of  his  condition 
were  taken  by  Dr.  Bury,  then  medical  registrar,  of  which  an 
abstract  only  is  here  given.  At  this  time  it  was  noted  that  costal 
respiration  was  still  deficient,  being  apparently  more  so  in  the 
lower  ribs  (probably  because  the  downward  traction  of  the  dia- 
phragm was  able  to  overcome  the  expansion). 

The  following  was  the  condition  of  the  right  upper  limb : — 
The  wrist  was  semiflexed  and  somewhat  inclined  towards  the  ulnar 
side,  having  very  slight  power  of  flexion  and  extension.  The 
thumb  lay  fully  extended,  but  could  be  slightly  flexed,  adducted 
and  abducted :  there  being,  however,  no  power  of  opposition. 
The  first  phalanges  of  the  fingers  were  extended,  the  second  and 
third  partially  flexed ;  there  was  slight  power  of  flexion  of  the 
metacarpo-phalangeal  joints,  but  no  movement  at  the  inter- 
phalangeal  joints.  As  regards  lateral  movement,  there  was  slight 
power  of  abduction  and  adduction  of  the  first  and  fourth  fingers, 
but  the  second  and  third  were  immovable,  having  always  a  slight 
interval  between  them.  He  could  pronate  the  wrist  and  then 
bring  it  half-way  into  the  supine  position,  but  no  further.  The 
elbow  was  semiflexed  and  could  be  partially  flexed,  but  not 
extended,  and  passive  extension  caused  the  tendon  of  the  biceps 
to  stand  out  very  sharply.  At  the  shoulder-joint  there  was 
diminished  movement,  especially  of  abduction,  external  rotation, 
and  flexion ;  he  could  touch  the  tip  of  the  opposite  shoulder,  but 
not  the  head.  There  was  marked  wasting  of  the  whole  limb. 
A  very  powerful  faradic  current  caused  slight  contraction  of  the 
extensors  and  flexors  of  the  elbow  and  of  the  serratus  magnus, 
but  of  none  of  the  other  muscles  of  the  limb  or  shoulder.  The 
galvanic  current  gave  the  "  reaction  of  degeneration "  with  the 
pectoralis  major,  deltoid,  supra-  and  infra-spinatus,  biceps,  triceps, 
extensors  and  flexors  of  the  forearm,  and  muscles  of  the  hypothe- 
nar  and  thenar  eminences.  On  the  left  side  the  condition  was 
similar,  except  that  there  was  even  less  power  of  voluntary  move- 
ment. In  brief,  there  was  well-marked  "  atrophic  paralysis  "  of  all 
muscles  supplied  by  the  brachial  plexus.  The  movements  of  the 
lower  limbs  were  weak,  but  of  normal  range,  except  for  some 
deficiency  at  the  left  ankle,  arid  the  electric  reactions  were  also 
here  normal. 


56  SURGERY    OF    THE   SPINAL    CORD. 

It  was  not  easy  to  map  out  accurately  the  extent  of  sensory  defi- 
ciency, owing  to  the  fact  that  there  was  nowhere  absolute  anaesthesia, 
nor  any  defined  limit.  On  both  sides  sensation  was  normal  in  the 
neck,  and  as  far  downwards  as  the  lower  limit  supplied  by  the 
cervical  plexus,  that  is,  to  the  level  of  the  third  rib.  There  was 
below  this  limit  marked  diminution  of  sensation  on  the  right  side, 
extending  to  within  half-an-inch  of  the  middle  line  in  front :  at 
this  point  there  was  an  area  of  transition,  and  to  the  left  of  the 
middle  line  sensation  was  normal.  Behind,  the  anaesthetic  area 
extended  over  the  whole  of  the  right  side  of  the  trunk  as  far  as 
a  vertical  line  midway  betweep  the  posterior  border  of  the  right 
scapula  and  the  spines  of  the  vertebrae ;  the  upper  limit  of  anaes- 
thesia being  here  the  spine  of  the  scapula.  The  right  shoulder 
was  not  anaesthetic.  There  was  no  anaesthesia  of  the  left  half  of 
the  trunk.  The  right  lower  limb  was  anaesthetic,  the  left  was 
not — in  fact,  there  was  partial  anaesthesia  of  the  whole  of  the 
right  side  of  the  trunk  and  lower  extremity,  with  normal  sen- 
sation on  the  left  side.  In  the  upper  limbs  the  distribution  of 
anaesthesia  was  symmetrical,  affecting  the  whole  •  of  the  limbs, 
excepting  a  strip  of  skin  running  from  the  shoulder  along  the 
centre  of  the  biceps,  and  then  straight  downwards  along  the 
front  of  the  forearm  to  the  hand,  where  it  spread  out,  so  that  the 
only  part  of  the  hand  which  was  anaesthetic  was  the  thumb,  the 
rest  having  apparently  normal  sensation  both  in  front  and  behind. 

The  knee-jerk  was  much  exaggerated,  and  there  was  marked 
ankle-clonus ;  the  superficial  reflexes  were  absent,  and  there  were 
no  reflexes  in  the  upper  limbs. 

The  skin  over  the  anaesthetic  areas  was  hot  and  dry,  the 
slightest  prick  or  scratch  causing  a  bright  red  spot  or  line. 
There  were  slight  swelling  and  tenderness  at  the  back  of  each 
wrist.  The  inter-phalangeal  joints  were  also  thought  to  be 
slightly  swollen,  but  were  probably  merely  rendered  more  promi- 
nent by  the  general  atrophy.  The  finger-nails  were  long,  the 
skin  at  their  roots  being  red,  smooth,  and  shining. 

The  left  pupil  was  slightly  smaller  than  the  right,  and  the  left 
palpebral  fissure  somewhat  narrowed. 

The  patient  remained  under  observation  for  rather  more  than 
three  months  more,  taking  a  mixture  of  iron  and  quassia.  During 
this  time  his'  voluntary  power  increased  considerably  in  the  right 
upper  extremity,  and  to  a  slight  extent  in  the  left;  when  last 
seen,  he  could  move  the  fingers  of  the  right  hand  fairly  well 
in  all  directions,  had  slight  power  of  opposition  of  the  thumb, 
could  raise  the  elbow  to  the  level  of  the  shoulder,  and  could  touch 


INJURIES    TO    THE    CERVICAL   REGION.  57 

the  top  of  the  head  with  his  hand.  Sensation  had  also  improved. 
There  was  still  some  difficulty  in  moving  the  left  ankle,  but 
otherwise  the  movements  of  the  lower  limbs  were  good. 

Superficial  reflexes  were  obtained  over  the  abdomen;  the  cre- 
masteric reflexes  were  still  absent,  the  plantar  was  got  on  the 
right  side  only.  The  knee-jerk  was  less  marked  on  the  right 
side  than  it  had  been,  but  was  unaltered  on  the  left.  There  was 
no  other  change,  and  the  vital  functions  were  well  performed. 

We  have  here  another  case  of  central  hsematomyelia,  in  which 
the  haemorrhage,  being  more  extensive  upon  the  left  side  of  the 
cord,  caused  the  paralysis  of  the  lower  limb  and  pupillary  fibres 
to  be  greater  on  that  side,  and  the  anaesthesia  to  be  more  marked 
in  the  right  lower  limb.  On  the  left  side  the  haemorrhage 
extended  into  the  region  of  origin  of  the  fourth  and  fifth  cervical 
nerves,  whereas  on  the  right  side  it  stopped  short  of  that  of  the 
fifth.  For  some  little  time  the  distribution  of  the  paralysis  was 
increased  by  the  spread  of  myelitis,  which,  like  the  haemorrhage, 
confined  itself  mainly  to  the  central  grey  matter  of  the  cord,  so  that 
eventually,  although  the  whole  of  the  brachial  motor  nuclei  were 
greatly  damaged,  their  muscles  being  left  atrophic  and  paralysed, 
there  was  but  slight  interference  with  the  conducting  fibres. 

The  sensory  affection  is  particularly  interesting.  Anaesthesia 
clearly  affected  the  distribution  of  the  highest  (say  the  fifth  cer- 
vical) and  the  lowest  (say  the  first  dorsal)  roots  of  the  brachial 
plexus  on  both  sides,  together  with  the  entire  sensory  tract  for 
the  right  side  below  the  level  of  the  brachial  region.  This  distri- 
bution can  be  explained  by  assuming  a  central  lesion  in  the  upper 
brachial  region,  which  would  involve  the  posterior  roots  of  the 
fifth  nerve  as  they  enter  the  cord  and  penetrate  towards  its  centre ; 
then  the  immediately  succeeding  roots,  ascending  for  some  little 
distance  in  the  peripheral  white  matter,  as  they  probably  do,  would 
escape  the  lesion.  As  we  proceed  lower,  we  find  the  first  dorsal 
sensory  root  completing  its  first  brief  peripheral  course,  and  entering 
the  grey  matter  at  about  the  level  of  the  lesion,  so  as  to  be  involved 
in  its  effects ;  and  finally,  the  greater  extent  of  the  lesion  of  the 
left  side  of  the  cord  explains  the  damage  done  to  the  whole  of  the 
remaining  ascending  fibres  from  the  right  side  of  the  body,  which 
are  again  probably  peripheral. 

In  order,  therefore,  to  reduce  the  explanation  of  the  symptoms 
to  a  single  lesion,  we  must  assume  that  the  sensory  fibres,  after 
entering  the  cord,  penetrate  nearly  to  its  centre ;  that  they  then 
ascend   for   some   little  distance  in  a  peripheral   position  before 


58  SURGERY    OF   THE   SPINAL    CURD. 

entering  (or  re-entering)  the  grey  matter  to  decussate  with  their,' 
fellows,  and  that,  finally,  after  a  brief  course  in  the  grey  matter,  i 
they  once  more  enter  the  white  substance,  and,  becoming  peripheral, 
remain  so  for  the  remainder  of  their  course.  Such  an  explana- 
tion appears  to  be  consistent  with  the  general  results  of  experi- 
ment as  to  the  direction  of  sensory  conduction  in  the  cord,  which 
seem  to  indicate  that  the  paths  enter  the  grey  matter  after  a 
brief  vertical  course,  but  that  they  subsequently  regain  the  white 
columns. 

The  record  of  the  following  case  is  very  incomplete,  but  the 
symptoms  will  be  found  to  be  entirely  explicable  by  the  diagnosis  of 
a  small  haemorrhage  in  the  upper  part  of  the  brachial  region,  causing 
but  slight  and  temporary  compression  of  the  fibres  of  the  cord, 
and  unaccompanied  by  any  serious  destruction  of  its  tissues. 


Case  20. — Traumatic  cervical  hmmatoinyelia — Temporari/  paralysis 
of  limhs  and  trunk — Recovery. 

W.  B.,  aged  forty,  was  admitted  to  Mr.  Heath's  wards  on 
August  15,  1885,  suffering  from  the  results  of  a  fall,  estimated 
at  a  distance  of  fifty  feet.  He  was  a  strong,  healthy-looking  man, 
with  no  trace  of  previous  illness.  On  the  right  side  of  the  head 
was  a  deep  scalp-wound,  extending  about  four  inches  backwards 
from  the  forehead,  and  surrounded  by  much  bruising.  It  may  at 
once  be  said  that  under  ordinary  treatment  this  wound  soon 
healed  up.  There  was  no  unconsciousness,  nor  other  trace  of 
cerebral  symptoms.  All  four  limbs  were,  however,  paralysed — 
the  arms  completely  so ;  the  legs  could  be  moved  in  bed,  but  the 
patient  could  not  stand.  He  had  complete  anaesthesia  of  the 
arms,  abdomen,  and  legs,  but  no  loss  of  control  over  the  rectum 
and  bladder.  The  skin  over  the  lumbar  spine  showed  extensive 
bruising.  Unfortunately  the  notes  of  this  case  were  very  imper- 
fectly taken,  and  there  is  no  further  information  contained  in  them. 

On  the  following  day  the  temperature  rose  to  99.2°  F.  in  the 
morning,  and  I00.8°  F.  in  the  evening;  there  was  more  power 
in  the  lower  limbs  and  muscles  of  the  neck.  On  August  1 7th 
he  could  move  his  legs  quite  easily  and  freely  in  bed,  and  there 
was  no  sign  of  paralysis  of  the  neck,  but  both  arms  remained 
completely  paralysed.  Sensibility  was  improved,  but  there  were 
tingling  sensations  in  all  the  limbs.  The  temperature  was  lower. 
On  the   1 8th  sensibility  appeared  to  have  quite  returned.     The 


INJURIES    TO    THE    CERVICAL   REGION.  59 

fingers  and  thumb  could  be  moved  fairly  well  on  both  sides,  and 
there  was  slight  movement  of  the  whole  upper  limb.  The  tempera- 
ture had  returned  to  the  normal,  at  which  it  afterwards  remained. 
From  this  time  there  was  a  slow  but  steady  gain  in  power,  and  on 
August  28th  the  upper  extremities  could  be  moved  in  any  direc- 
tion, although  only  feebly  so.  It  was,  however,  some  time  before 
the  legs  were  sufficiently  strong  to  support  the  weight  of  the  body. 
He  was  first  able  to  walk  a  little  on  October  1 2th,  and  could  then 
use  his  arms  for  such  light  work  as  holding  a  book,  but  they  were 
still  weak ;  there  was  no  distinct  muscular  wasting ;  ankle-clonus, 
and  the  patellar,  triceps,  and  radial  reflexes  were  exaggerated. 
The  only  affection  of  sensibility  was  some  numbness  of  the  inner 
sides  of  the  calves,  with  tingling  sensation  in  the  fingers. 

Three  days  later  he  was  sent  to  the  Convalescent  Hospital  at 
Cheadle,  where  the  constant  current  .was  applied  to  various  parts 
of  the  limbs  three  times  weekly,  and  where  strength  rapidly 
returned. 

I  again  saw  the  patient  on  January  16,  1886,  i.e.,  five  months 
after  his  accident.  He  then  looked  very  well  and  had  returned 
to  his  work,  but  still  felt  weakly,  and  had  the  sensation  of  tingling 
in  the  fingers  ;  there  was,  however,  no  aneesthesia,  and  no  diffi- 
culty in  using  the  hand.  He  stated  that  at  times  he  had  some 
girdling  sensation,  which  he  referred  to  the  region  of  the  lower 
dorsal  and  upper  lumbar  nerves.  The  patellar  and  radial  "  deep 
reflexes"  were  exaggerated,  but  there  was  no  ankle-clonus  and 
no  jerk  on  striking  the  triceps  tendon. 

Owing  to  the  want  of  an  accurate  clinical  examination,  we  have 
no  evidence  as  to  the  exact  locality  of  heemorrhage  in  this  case, 
but  the  general  course  is  so  similar  to  that  of  our  other  cases  of 
haematomyelia,  that  we  can  hardly  doubt  that  the  case  was  of  the 
same  nature,  and  would,  if  properly  examined,  have  yielded 
evidence  of  eff'usion  into  some  of  the  spinal  nuclei.  It  is  the 
absence  of  such  examination  in  cases  of  this  nature  which  leads 
them  to  be  described  as  "  concussion  of  the  cord." 


Case  21. — Gunshot  injury  to  the  spinal  cord — Paralysis  of 
limbs  and  trunk — Partial  recovery. 

M.  H.,  a  widow,  aged  thirty-seven,  was  admitted  under  the 
care  of  Mr.  Jones  on  May  10,  1886.  Five  weeks  previously 
she  received  two  bullet-wounds  from  a  revolver,  probably  fired 
at  a  distance  of  about  two  yards.      One  bullet  pierced  the  left 


60  SURGERY   OP    THE    SPINAL   CORD. 

thumb  and  tlien  passed  through  the  lobe  of  the  left  ear,  grazing 
the  mastoid  process,  and  apparently  at  once  escaping.  The  other 
entered  immediately  below  and  behind  the  left  mastoid  process, 
passing  downwards  and  to  the  right.  She  was  '''  immediately  " 
paralysed  in  all  four  limbs,  and  when  seen  by  a  medical  man  was 
found  to  have  complete  loss  of  sensation  below  the  neck,  dia- 
phragmatic breathing,  and  incontinence  of  urine  and  faeces.  An 
attempt  was  made  to  find  the  bullet,  but  proved  unsuccessful. 
The  wounds  healed  well  in  about  a  fortnight,  during  which  time 
the  nervous  symptoms  were  said  to  have  remained  unchanged. 
Calomel  was  occasionally  administered  to  regulate  the  bowels,  and 
the  limbs  were  rubbed  with  oil. 

On  admission  to  the  Infirmary  five  weeks  after  the  injury,  she 
was  found  to  be  a  well-nourished  and  healthy-looking  woman. 
In  addition  to  the  scars  left  by  the  above-mentioned  wounds,  she 
presented  the  following  symptoms : — At  the  back  of  the  neck 
some  three  inches  to  the  right  of  the  fifth  cervical  spinous  pro- 
cess, was  felt  a  hard  nodule,  apparently  the  bullet,  lying  quite 
superficially.  She  felt  pain  on  moving  the  head,  and  tenderness 
of  the  cervical  spine.  There  were  no  cerebral  symptoms.  The 
upper  limbs  were  completely  paralysed.  The  lower  extremities 
were  less  absolutely  so :  on  the  left  side  she  had  some  power  of 
extension  and  flexion  of  the  ankle-joint,  and  could  raise  the  limb 
slightly  from  the  bed ;  on  the  right  side  there  was  somewhat  less 
power  of  movement  of  the  ankle.  The  abdominal  and  intercostal 
muscles  were  also  paralysed,  breathing  being  diaphragmatic.  There 
was  no  anaesthesia,  but  slight  hyperaesthesia  about  the  shoulders. 
The  superficial  and  deep  reflexes  were  normal.  The  limbs  did 
not  appear  wasted.  There  was  incontinence  of  urine  and  faeces. 
The  temperature  •  was  normal,  and  remained  so  throughout  the 
patient's  stay  in  hospital.  There  were  no  circulatory  or  digestive 
disturbances. 

A  few  days  later,  Mr.  Jones  removed  the  bullet  without 
difficulty  from  the  site  above  indicated.  It  proved  to  be  a  conical 
revolver-bullet,  about  three-quarters  of  an  inch  long,  and  flattened 
at  the  apex  from  contact  with  some  hard  substance.  The  wound 
healed  readily,  and  gave  no  trouble.  The  faradic  current  was  here- 
after regularly  applied  to  the  limb-muscles,  the  electric  reactions  of 
which  were  normal. 

On  May  19th  were  noted  involuntary  twitchings  of  the  legs, 
which  were  very  constantly  present,  and  continued  during  her 
stay  in  hospital.  On  the  25  th  she  was  found  to  have  some 
slight  power  of  movement  of  the  fingers  of  her  left  hand,  and 


INJURIES   TO    THE    CERVICAL   REGION.  6 1 

increasing  power  in  the  movements  of  the  feet.  Shortly  after 
this  she  commenced  to  move  the  abdominal  muscles,  and,  to  a 
slight  extent,  the  intercostals,  the  power  of  all  of  these  slowly- 
increasing.  Towards  the  middle  of  June  she  became  able  to 
move  slightly  the  fingers  of  the  right  hand,  but  there  was  little 
improvement  elsewhere.  She  complained  a  good  deal  of  occa- 
sional wandering  sensations,  of  "  pins  and  needles,"  and  of  the 
almost  constant  muscular  tremors.  From  this  time  until  she 
went  home  on  July  30th,  there  was  no  change,  except  a  slight 
increase  in  the  power  of  the  already-acquired  movements. 

By  kind  permission  of  Dr.  Martin,  her  medical  adviser,  I  saw 
this  patient  again,  at  her  own  home,  in  September.  As  regards 
motor  power,  there  was  little  or  no  change  from  the  time  of  her 
leaving  the  Infirmary.  The  limbs  were  not  more  wasted  than 
would  be  expected  from  her  long  confinement  to  bed,  and  the 
muscles  everywhere  presented  normal  electric  reactions.  The 
knee-jerk  was  much  exaggerated,  and  there  was  ankle-clonus  on 
both  sides ;  the  radial,  ulnar,  and  triceps  reactions  were  absent. 
She  had  complete  control  over  the  bladder  and  rectum.  There 
was  no  anaesthesia.  The  pupils  were  normal.  She  complained 
greatly  of  pain  in  the  various  joints,  but  especially  in  the  left 
elbow  and  ankle.     The  general  health  had  remained  good. 

About  a  year  later  I  heard  incidentally  of  the  death  of  this 
patient ;  but  was  unable  to  obtain  any  further  details  or  per- 
mission for  an  autopsy. 

This  case  presents  so  many  points  of  similarity  to  the  five 
which  precede  it,  that  we  are  naturally  led  to  seek  in  the  latter 
the  explanation  of  the  symptoms.  There  is  the  same  sudden 
pai'alysis  with  anaesthesia,  followed  by  spastic  symptoms,  the 
anaesthesia  passing  off  gradually,  the  bladder  and  rectum,  at 
first  paralysed,  recovering  their  functions.  There  is,  however, 
this  important  difference,  that  whereas  hitherto  we  have  had 
evidence  of  destruction  of  a  portion  of  the  grey  matter  of  the  cord, 
generally  leaving  a  localised  atrophic  paralysis  and  some  permanent 
impairment  of  sensation,  but  allowing  of  much  recovery  in  the 
case  of  the  descending  tracts,  there  are  here  no  atrophic  symptoms, 
but  there  is  extensive  and  permanent  injury  to  the  descending 
motor  tracts.  Further,  in  the  present  instance  the  symptoms 
are  absolutely  symmetrical.  We  are  thus  led  to  look  for  some 
cause  of  general  compression  of  the  cord  at  a  point  near  the  upper 
part  of  the  brachial  region.  In  the  earlier  cases,  the  compressing 
agent  was  a  central  haemorrhage,  causing  some  destruction  of  the 


62  SURGERY    OF   THE    SPINAL    CORD. 

grey  matter  in  its  immediate  vicinity.  In  the  present  instance 
we  can  hardly  assume  this  to  have  been  the  nature  of  the  lesion, 
as,  if  we  do  so,  we  must  suppose  an  effusion  of  blood  large  enough 
to  cause  continued  pressure  on  the  whole  of  the  structures  of  the 
cord,  and  yet  so  small  as  not  to  have  extended  into  the  anterior 
cornua  and  produced  any  muscular  atrophy.  If,  however,  the 
lesion  were  meningeal,  lying  entirely  outside  the  cord,  it  might 
very  well  cause  such  pressure  without  producing  any  serious 
destruction  of  its  substance.  But  a  moment's  consideration  will 
show  that  the  accident  was  of  just  such  a  nature  as  to  produce  this 
injury.  An  examination  of  the  neck,  or  of  such  a  plate  as  that 
given  on  p.  302,  vol.  i.,  of  Quain's  "Anatomy"  (eighth  edition), 
will  show  that  if  a  bullet  were  to  enter  "  immediately  below  and 
behind  the  left  mastoid  process,"  and  pursue  a  straight  course  to 
a  point  "  some  three  inches  to  the  right  of  the  fifth  cervical  spinous 
process,"  it  would  cross  the  vertebral  column  about  the  level  of 
the  fourth  cervical  spine,  that  is,  about  the  level  of  exit  of  the 
fifth  cervical  nerves,  the  upper  limit  of  the  paralysis  and  aneesthesia 
in  our  case.  Now,  the  bullet  was  flattened  at  the  apex,  as  if 
it  had  struck  some  bone,  and  as  it  entered  below  the  mastoid 
process,  the  only  bone  in  its  track  would  be  a  portion  of  the 
spine.  It  would  then  appear  that  the  bullet  struck  the  spinal 
column  somewhere  immediately  above  the  point  of  exit  of  the 
fifth  cervical  nerves,  there  injuring  the  cord,  either  by  a  direct 
wound,  by  an  indirect  wound  due  to  bony  splinters,  or  by  causing 
a  meningeal  haemorrhage. 

In  concluding  a  review  of  the  above  cases,  there  are  a  few 
points  to  which  reference  may  be  made,  and  for  the  consideration 
of  which  it  is  more  convenient  to  regard  the  cases  collectively. 

We  are  at  once  struck  by  the  relatively  large  number  of  cases 
of  haemorrhage  within  the  vertebral  canal,  unaccompanied  by 
any  evidence  of  injury  to  the  spine  itself,  constituting  at  least 
five,  or,  if  we  include  the  last  case,  six,  out  of  a  total  of  twenty-one 
cases  of  injury  to  the  cervical  region  of  the  spine.  The  number  of 
these  cases  occurring  in  actual  practice  is  probably  much  under- 
estimated, many  of  them  being  regarded  as  instances  of  concussion 
of  the  spine,  without  definite  organic  lesion.  The  symptoms  are 
frequently  complicated,  and,  without  a  careful  consideration  of 
the  origin  and  course  of  the  affected  tracts,  would  appear  to  be 
inexplicable  on  the  hypothesis  of  a  single  lesion.  If,  however, 
these  symptoms  be  fully  investigated  with  the  assistance  of  an 
accurate   knowledge    of   the    anatomy    of   the    cord,    they    will 


INJURIES    TO    THE    CERVICAL    REGION.  63 

probably  in  most  cases  be  found  to  be  clearly  due  to  some 
gross  local  lesion.  It  is  to  be  regretted  that  of  the  numerous 
reported  cases  of  spinal  injury,  a  minority  only  are  sufficiently 
detailed  to  permit  of  an  accurate  diagnosis,  it  being  too  cus- 
tomary to  use  such  loose  expressions  as  "  partial  paralysis  of  the 
upper  limbs." 

Another  cause  of  the  comparative  neglect  of  hsematomyelia  as 
a  result  of  injuries  to  the  spine  is  the  relative  infrequency  of 
post-mortem  examinations  verifying  this  condition.  These  cases 
are  not  nearly  so  fatal  as  fractures  and  dislocations,  and  their 
true  pathology  is  therefore  not  generally  recognised.  Thus  we 
find  that  of  fifteen  cases  of  fracture  or  dislocation,  all  but  one 
were  fatal,  whereas  of  the  six  cases  of  hsemorrhage  only  two  died, 
and  in  the  last,  in  which  the  diagnosis  is  doubtful,  death  followed  at 
so  long  an  interval,  that  the  case  had  passed  from  under  observation. 
Under  these  circumstances  the  only  possible  means  of  diagnosis  is 
the  demonstration  that  all  the  symptoms  may  be  due  to  a  single 
focus  of  injury ;  but  where  such  demonstration  is  practicable,  a 
diagnosis  of  hsemorrhage  should  always  be  preferred  to  the  vague 
and  unsatisfactory  designation  "  concussion  of  the  spinal  cord." 

An  excellent  illustration  of  the  importance  of  excluding 
hsematomyelia  before  rejecting  the  diagnosis  of  an  organic  lesion 
is  referred  to  by  Mr.  Page,^  who,  criticising  a  case  of  Dumenil  and 
Petit,  suggests  that  the  symptoms  which  they  attribute  to  con- 
cussion might  have  been  due  to  a  gross  lesion  caused  by  bending 
of  the  spine.  The  case  referred  to  is  strikingly  similar  to  the  above 
examples  of  haematomyelia,  and  all  the  symptoms  might  have  been 
produced  by  a  central  haemorrhage  at  the  upper  part  of  the  origin 
of  the  sixth  cervical  root,  a  diagnosis  with  which  the  post-mortem 
appearances  are  entirely  consonant.  A  similar  accurate  study 
will  undoubtedly  eliminate  many,  at  present,  obscure  cases  of 
"  concussion." 

The  tendency  of  haematomyelia  to  afiect  the  centre  of  the  cord 
— the  grey  matter,  especially  of  the  anterior  cornua,  and  the 
central  canal — is  illustrated  by  all  of  these  cases,  as  well  as  by 
several  of  those  referred  to  in  Chapter  I.,  in  which  a  spinal  lesion 
was  accompanied  by  an  extensive  central  hagmorrhage. 

The  symptoms  produced  by  such  a  heemorrhage  are  divisible 
into  two  groups,  just  as  are  the  symptoms  of  a  cerebral  heemor- 
rhage  :  we  have  a  "  destroying  "  and  a  "  compressing  "  lesion — 
the  former  permanent,  the  latter  more  or  less  temporary.  As  a 
result  of  the  destroying  lesion,  we  find  atrophic  paralysis  and 

1  Brain,  1886,  vol.  ix.  p.  258. 


64  SURGERY    OF    THE    SPINAL    CORD. 

possibly  persistent  anaesthesia  in  the  distribution  of  some  of  the 
roots  of  the  brachial  plexus.  The  compressing  lesion  may  cause 
more  or  less  complete  paralysis  and  anaesthesia  below  its  level, 
with  retention  of  urine  and  feeces,  priapism,  contraction  of  the 
pupil,  and  other  symptoms,  which,  as  a  rule,  soon  subside,  pro- 
bably leaving  only  some  spastic  symptoms  in  the  lower  limbs. 

Another  important  point  illustrated  by  the  above  cases  is, 
the  method  of  production  of  these  intramedullary  haemorrhages. 
Two  theories  are  possible  ;  one,  that  the  cord  is  "  concussed,"  or 
jerked  violently  backwards  or  forwards  against  its  containing 
canal,  and  thus  bruised ;  the  other,  that  there  has  in  all  cases 
been  a  diastasis  or  partial  dislocation  with  recoil.  The  former  xVCD 
view  appears,  however,  to  be  untenable."  Thus,  in  Case  1 6,  had  '^j 
the  lesioh  been  due  to  concussion,  we  should  have  expected  the 
post-mortem  evidence  of  the  bruise  to  the  delicate  cord  to  have 
extended  over  a  wider  and  less  sharply  defined  area  than  that 
which  the  haemorrhage  actually  occupied  ;  the  cord  must  have 
been  driven  forwards  en  masse,  and  there  is  no  reason  why  the 
injury  inflicted  should  be  thus  localised.  Similarly,  in  several  of 
the  other  non-fatal  cases,  the  symptoms  prove  the  haemorrhage  to 
have  been  of  small  extent.  An  acute  bend,  on  the  other  hand, 
might  readily  produce  a  lesion  of  this  nature,  and,  in  fact,  we  find 
in  Cases  4,  1 1 ,  and  15a  condition  which  is  practically  a  hgemato- 
myelia,  in  which  the  injury  to  the  cord  had  undoubtedly  resulted 
from  a  displacement  of  the  vertebrae,  reduced  in  the  first  two  cases 
by  nature,  and  in  the  third  by  art. 

The  region  in  which  haematomyelia  is  found  to  occur  also 
favours  this  view  of  its  production.  In  all  the  above  cases  it 
was  located  in  a  small  area,  limited  by  the  region  of  origin  of 
the  four  lower  cervical  and  the  first  dorsal  nerves,  a  region  corre- 
sponding to  the  bodies  of  the  fourth,  fifth,  and  sixth  cervical 
vertebrae.  Above  or  below  this  section  of  the  cord  I  have  not 
met  with  a  single  instance  of  traumatic  haematomyelia — a  fact 
totally  inexplicable  on  the  concussion  theory.  This  is,  however, 
the  summit  of  the  arch  formed  by  the  cervical  curve,  and  is, 
therefore,  the  region  in  which  an  acute  bend  of  the  neck  would 
make  itself  mainly  felt,  especially  if  the  effects  of  such  a  bend 
were  spread  over  several  vertebrae,  straining  somewhat  the  articu- 
lations of  each  without  giving  rise  to  a  dislocation.  In  fig.  5 
is  illustrated  the  probable  pathology  of  such  a  lesion ;  the  con- 
nections of  several  of  the  cervical  vertebree  have  partially  yielded, 
and  the  bending  of  the  spinal  tube  has  bruised  the  cord  near  the 
apex  of  the  curve,  and  has  there  caused  a  hasmatomyelia. 


INJURIES   TO   THE   CERVICAL   REGION.  65 

Sucli  facts  as  are  obtainable  regarding  the  exact  nature  of  the 
accident  are  also  in  favour  of  the  "  flexion  "  as  against  the  "  con- 
cussion" theory.  Thus,  in  Cases  16  and  20,  the  occurrence  of 
severe  scalp-wounds  appears  to  indicate  that  the  force  of  the  blow 
received  was  in  each  case  delivered  upon  the  head,  and  would  thus 
tend  unduly  to  bend  the  cervical  spine.  In  Case  1 7,  the  accident 
was  a  fall  upon  the  hands,  which  would  imply  a  severe  jerk  to  the 
head  and  neck,  and  would  thus  cause  sharp  flexion  of  the  latter. 
In  Case  1 8,  the  patient  fell  flat  upon  his  back,  so  that  the  afiected 
region  would  be  less  exposed  than  any  other  part  of  the  spine  to 
a  direct  impact  and  to  concussion,  but  correspondingly  more 
liable  to  flexion.  Finally,  in  Case  19,  the  passing  of  a  wheel 
over  the  shoulders  is  an  injury  too  slow  in  its  action  to  "  concuss  " 
or  jerk  the  cord  forwards,  but  is  one  well  calculated  to  produce 
bending  of  the  spinal  column. 


CHAPTER    III. 

INJURIES  TO  THE  DORSAL  REGION  OF  THE 
SPINAL  CORD. 

Owing  to  the  comparative  simplicity  of  the  distribution  of  the 
dorsal  nerves,  and  especially  to  the  absence  of  plexuses  upon  their 
course,  the  symptoms  presented  by  injuries  of  this  region  of  the 
spinal  cord  are  much  less  complicated  than  those  which  arise 
when  the  cervical  or  lumbar  enlargement  has  been  implicated. 
As  a  result  of  this  simplicity,  the  difficulties  of  localisation  become 
comparatively  trivial ;  and  hence,  injuries  of  the  dorsal  region 
illustrate  more  clearly  than  those  of  any  other  the  general  char- 
acters of  lesions  of  the  spinal  cord.  For  this  reason,  the  following 
cases  are  here  recorded,  and  attention  will  be  called  to  some  of 
the  more  interesting  points  which  they  present. 

As  previously  stated,  I  have  not  met  with  any  cases  of  menin- 
geal or  intra-medullary  haemorrhage  in  this  region  ;  and  the  follow- 
ing examples,  constituting  the  series  of  cases  observed  during  the 
last  four  years  in  the  Manchester  Infirmary,  are  all  doubtless 
instances  of  fracture  or  dislocation. 


Case  22. — Fracture-dislocation  of  third  or  fourth  dorsal  verteJyra. 

D.  E.  H,,  a  woman,  aged  thirty-one,  was  admitted  to  Mr. 
Hardie's  wards  in  the  Manchester  Infirmary  on  April  12,  1889, 
having  shortly  before  fallen  backwards  out  of  a  window  some 
fifteen  or  twenty  feet  from  the  ground.  She  was  found  in  an 
unconscious  condition,  with  an  extensive  scalp-wound  on  the  back 
of  the  head,  as  well  as  several  bruises  on  the  limbs. 

It  was  not  until  consciousness  returned  on  the  following  day 
that  the  spinal  injury  was  noticed.  She  then  presented  complete 
paralysis  and  anaesthesia  below  the  level  of  the  fourth  ribs,  with 


INJURIES    TO    THE   DOESAL    REGION". 


67 


a  hyperaestlietic  band  corresponding  to  the  third  intercostal  space. 
All  the  superficial  and  deep  reflexes  were  lost  below  the  site  of 
the  lesion.  Urine  and  faeces  were  retained ;  respiration  was 
mainly  abdominal,  but  without  dyspnoea;  the  pulse  was  g6 -, 
temperature  normal.  The  skin  of  the  lower  limbs  felt  very  dry, 
and  the  patient  complained  much  of  a  sensation  of  coldness  in 
them.  The  urine  was  neutral,  of  sp.  gr.  1 03 2,  and  free  from 
albumin  or  sugar. 

She  had  but  little  pain  or  tenderness  of  the  back,  nor  any 
pain  on  vertical  pressure  upon  tbe  head  ;  but  one  of  the  dorsal 
spinous  processes — whether  the  third  or  fourth  could  not  be 
accurately  determined — was  markedly  prominent  as  compared 
with  that  immediately  below  it. 

The  surface-temperature  was  taken  on  several  occasions  above 
and  below  the  lesion,  the  results  being  as  follows  : — 


April  15. — Surface  of  front  of  thigh 

Surface  of  front  of  arm 

Axilla. 
April  16. —  Surface  of  front  of  thigh 

Surface  of  front  of  arm 

Axilla  .... 
April  17. — Surface  of  front  of  thigh 

Surface  of  front  of  arm 

Axilla  .... 
April  18. — Surface  of  front  of  thigh 

Surface  of  front  of  arm 

Axilla  .... 
April  29. — Surface  of  front  of  thigh 

Surface  of  front  of  arm 

Axilla  .... 
May  16. — Surface  of  front  of  thigh  before  using  battery 

Surface  of  front  of  thigh  after  using  battery 

Surface  of  front  of  arm         .... 

Axilla  ........ 

May  17. — Surface  of  front  of  thigh  before  using  battery 

Surface  of  front  of  thigh  after  using  battery 

Surface  of  front  of  arm         .... 

Axilla 


Difference  in 
favour  of  thigh. 

86.8° 


88.8° 
98.4° 
88.4° 
90.8° 
98.0° 
88.0° 


-  2.0 


-2.4 


9S.4" 
87.0° 
88.2° 
98.4° 
86.8° 
87.8° 
98.0° 
87.7° 
85.2° 
87.2° 
98.4° 
90° 


38-5 
98.4° 


+  0-5° 


+  1-5 


The  optic  discs  were  examined  and  found  to  be  normal  on 
April  16,  April  23,  and  May  16. 

These  symptoms  underwent  very  little  change  during  the 
next  few  weeks.  The  bowels  were  moved  for  the  first  time  on 
the  eighth  day,  and  were  thereafter  evacuated  daily.  About  the 
fifteenth  day  the  patient  began  to  complain  of  tingling  and 
pricking  in  the  feet  and  lower  limbs,  which  gradually  increased 
in  intensity,  and  then  gave  place  to  pain  suflSciently  severe  to 


68  SURGERY    OF    THE    SPINAL    CORD. 

interfere  with  sleep.  No  return  of  sensation  or  motion  in  the 
limbs  accompanied  these  changes,  but  at  the  same  time  the 
patient  began  to  be  occasionally  conscious  that  the  bladder  was 
full.  If  the  urine  was  then  not  drawn  off,  it  was  shortly  passed 
involuntarily. 

When  the  last  note  was  taken  on  May  i6,  the  distribution  of 
paralysis  and  anaesthesia  were  unaltered,  but  the  hypereesthesic 
band  had  entirely  disappeared.  A  feeble  jerk  was  obtained  on 
percussing  the  ligamentum  patellge  of  the  right  side  only.  The 
superficial  reflexes  were  still  absent.  The  rectum  appeared  to 
have  regained  its  functions,  the  condition  of  the  bladder  being 
as  above  described.  On  the  feet  were  several  large  bullge  filled 
with  blood,  but  the  skin  did  not  give  way.  The  skin  of  the 
lower  limbs  still  felt  dry,  but  they  often  perspired  freely  at 
night. 

Case  23. — Fracture-dislocation  of  fifth  (?)  dorsal  vertehra. 

H.  S.,  a  slater,  aged  forty-four,  was  admitted  to  the  Manchester 
Infirmary  under  the  care  of  Mr.  Whitehead  on  May  21,  1888. 
Shortly  before  admission  he  had  fallen  from  a  building  of  con- 
siderable height  on  to  his  head,  finally  alighting  with  his  back  on 
a  heap  of  bricks.  He  presented  a  scalp-wound  about  the  junction 
of  the  left  parietal  with  the  occipital  bone,  and  signs  of  frac- 
ture of  the  base  of  the  skull — bleeding  from  the  left  ear,  left 
facial  paralysis,  &c.  The  latter  need  not  now  be  further  referred 
to,  except  that  it  may  be  stated  that  the  patient  became  very  deaf 
and  considerably  demented. 

I  only  saw  the  case  a  few  days  after  admission,  and  then 
found  the  man  conscious.  He  complained  of  pain  in  the  mid- 
dorsal  region,  and  there  was  slight  angular  curvature  in  the 
region  of  the  fifth,  sixth,  and  seventh  dorsal  vertebras,  the  spine 
of  the  sixth  being  especially  prominent  and  also  obviously  de- 
tached. On  admission  the  deformity  had  been  more  marked,  but 
it  was  much  reduced  by  the  supine  position.  No  pain  was  caused 
by  pushing  down  the  shoulders. 

The  lower  limbs  and  the  abdominal  muscles  were  completely 
paralysed,  and  aneesthesia  apparently  extended  as  high  as  the 
sixth  intercostal  space,  having  a  slight  margin  of  hypera?sthesia 
above  it ;  but  owing  to  the  patient's  mental  condition,  the  exact 
boundary  (which  was  not  sharply  defined)  could  not  be  certainly 
identified.  The  urine  was  retained,  and  after  May  30th  be- 
came alkaline  and  offensive,  the  catheter  having  been  used  in 


INJURIES    TO    THE   DORSAL   REGION.  69 

the  meantime.  For  several  days  he  had  marked  priapism  ;  but 
after  I  first  saw  him  this  came  on  only  when  the  catheter  was 
passed,  there  being,  however,  persistent  slight  turgidity  of  the 
penis. 

The  plantar  and  cremasteric  reflexes  were  retained,  although 
the  latter  was  very  feebly  developed ;  the  knee-jerks  were  lost, 
as  were  the  abdominal  and  epigastric  reflexes. 

Three  weeks  after  admission  the  paralysis  and  anaesthesia  were 
as  before,  but  the  hypersesthetic  zone  had  disappeared.  The  sixth 
rib  was  now  definitely  ascertained  to  be  the  upper  limit  of  the 
anaesthesia.  The  plantar  reflexes  were  much  exaggerated,  the 
cremasteric  distinct,  and  the  abdominal  absent.  The  knee-jerk 
was  still  absent.  On  scratching  the  skin  of  the  lower  limbs 
flushing  was  readily  produced.  The  turgidity  of  the  penis  had 
quite  disappeared.  The  urine  was  purulent  and  very  foetid, 
although  the  bladder  was  being  washed  out  twice  daily  with  an 
antiseptic  solution.  The  temperature  was  normal  during  his 
long  stay  in  hospital,  except  for  occasional  fluctuations  of  no 
special  import. 

From  this  time  until  October  24,  1888,  when  he  was  dis- 
charged, the  man  showed  no  changes  of  consequence.  The  con- 
dition of  the  bladder  gradually  improved,  but  there  was  never 
any  return  of  power  or  sensation  in  the  limbs  and  trunk.  Even 
at  the  end  of  five  months  the  knee-jerks  remained  absent,  and 
although  the  lower  limbs  became  much  wasted,  there  was  no 
contracture.  The  progress  of  this  patient's  case  after  he  left  the 
Infirmary  is  unknown  to  me,  but  I  hear  that  he  died  in  April 
1889,  exhausted,  and  with  very  extensive  bed-sores. 


Case  24. — Fracture-dislocation  of  sixth  dorsal  vertebra. 

J.  H.  was  admitted,  under  the  care  of  Mr.  Whitehead,  on 
December  10,  1885.  He  was  a  strongly-built  young  man, 
twenty-four  years  of  age,  and  had  been  injured  by  an  iron  pipe, 
of  unknown  weight,  falling  upon  him. 

In  addition  to  simple  fractures  of  the  left  tibia,  radius,  and 
ulna,  he  presented  the  following  symptoms : — There  was  complete 
paralysis  and  loss  of  sensation  of  the  lower  extremities,  and  of 
the  trunk  as  high  as  the  eiofhth  rib,  with  retention  of  urine  and 
faeces.  There  was  great  pain  in  the  lower  dorsal  spine,  but  no 
deformity.  He  complained  much  of  difficulty  in  breathing,  and 
coughed  up  a  little  blood.      The  temperature  was  102.6°. 


JO  SURGERY    OF   THE   SPINAL   CORD. 

The  notes  of  this  case  are  very  imperfect,  but  tell  us  that 
shortly  after  admission  symptoms  of  pneumonia  were  developed, 
with  very  painful  cough  and  sanguineous  sputa.  On  the  fifth 
day  the  urine  became  alkaline.  The  temperature  oscillated 
somewhat,  but  was  generally  between  102°  and  103°,  until 
August  16,  the  sixth  day  after  admission.  On  the  morning  of 
that  day  it  was  102.2°;  at  1.25  P.m.  he  had  a  rigor,  and  it  rose 
to  103.8°;  at  1.45  it  was  106.2°;  at  2  p.m.  107.6°.  Breath- 
ing now  became  purely  diaphragmatic,  and  he  died  during  the 
afternoon. 

Dr.  Harris  found  the  following  appearances  at  the  post-mortem 
examination  : — The  spines  of  the  fifth,  sixth,  and  seventh  dorsal 
vertebrae  were  broken  off",  as  were  the  transverse  processes  on 
the  right  side  of  several  of  the  dorsal  vertebrae.  The  cartilages 
above  and  below  the  sixth  dorsal  vertebra  were  both  ruptured,  the 
body  of  the  vertebra  being  displaced  backwards  and  split  verti- 
cally. At  this  point  the  cord  was  completely  divided,  the  two 
ends  being  separated  by  a  distance  of  i-|^  inch,  and  the  dura  and 
pia  mater  stretched  across  from  one  to  the  other.  Above  and 
below,  the  cord  was  softened  and  infiltrated  with  blood  for  a  dis- 
tance of  about  two  inches  in  each  direction.  The  membranes 
were  healthy,  except  that  there  was  a  slight  laceration  of  the  dura 
mater  opposite  the  seat  of  injury. 

Both  pleura  contained  a  large  quantity  of  dark  blood,  fluid  and 
in  coagula.  The  lung-tissue  on  both  sides  was  contused  and 
infiltrated  with  blood,  and  the  lungs  cedematous. 


Case  25, — Fracture-dislocation  of  seventh  dorsal  vertebra. 

J.  S.  W.  was  admitted  into  Mr.  Heath's  wards  in  the  Manchester 
Royal  Infirmary  on  May  17,  1887.  He  had  been  injured  by  a 
bale  of  goods  falling  upon  him  from  a  great  height,  and  presented 
the  symptoms  of  shock  with  complete  paralysis  and  loss  of  sensa- 
tion "  below  the  level  of  the  seventh  dorsal  vertebra."  He  died  in 
a  few  hours. 

At  the  post-mortem  examination  was  found,  in  addition  to 
fracture  of  the  right  thigh,  and  rupture  of  the  stomach,  spleen,  and 
left  kidney,  a  fracture  of  the  seventh  dorsal  vertebra  extending 
through  its  body  obliquely  from  above  and  behind  downwards  and 
forwards.  The  articular  processes  were  dislocated,  and  the  spinal 
column  was  here  movable  in  all  directions,  the  bones  being  held  in 


INJURIES    TO    THE   DORSAL   REGION.  71 

apposition  only  by  the  soft  structures.  There  was  a  large  quantity 
of  blood  in  the  spinal  canal  outside  the  dura  mater,  and  the  cord 
opposite  the  seat  of  the  lesion  was  almost  torn  across,  only  a  few 
shreds  of  its  tissue  remaining. 


Case  26. — Fracture-dislocation  of  ninth  dorsal  vertebra. 

J.  D.,  a  labourer,  aged  thirty,  was  admitted  to  the  Manchester 
Infirmary  under  the  care  of  Mr.  Heath  on  December  11,  1888. 
In  the  previous  March  he  had  fallen  about  fifty  feet  from  the  top 
of  a  building,  the  fall  being  partially  broken  by  his  back  striking 
a  beam  some  thirty  feet  from  the  ground.  He  was  taken  to  the 
Ashton  Infirmary,  where  he  remained  until  September  without 
undergoing  any  improvement  in  his  symptoms. 

On  admission  to  the  Manchester  Infirmary,  he  was  found  to 
have  marked  prominence  of  the  spine  of  the  tenth  dorsal  vertebra, 
the  process  immediately  above  being  depressed.  The  back  was 
straight,  without  angular  curvature  or  deviation  of  the  spines  from 
the  middle  line. 

The  lower  limbs  were  completely  paralysed  and  their  muscles 
tonically  contracted,  causing  them  to  lie  quite  straight,  with  the 
toes  pointing.  The  plantar  and  cremasteric  reflexes  were  lost. 
The  knee-jerk  was  well  marked,  although  not  much  exaggerated  ; 
ankle-clonus  could  not  be  investigated  owing  to  contraction  of 
the  calf-muscles.  The  faradic  current  caused  no  contraction  in 
any  of  the  muscles  except  those  in  the  front  of  the  left  thigh, 
which  reacted  slightly  to  very  powerful  stimuli. 

Anaesthesia  was  complete  below  a  line  corresponding  accu- 
rately to  the  upper  limit  of  the  distribution  of  the  last  dorsal 
nerve. 

The  urine  dribbled  away  almost  constantly,  bladder-dulness  ex- 
tending as  high  as  midway  from  the  pubes  to  the  umbilicus.  The 
urine  was  alkaline,  purulent,  and  foetid.  On  one  occasion,  when 
a  soft  rubber  catheter  had  been  half  introduced,  it  was  forced  out 
again  by  a  spasmodic  contraction,  followed  by  a  stream  of  urine, 
which  did  not,  however,  empty  the  bladder.  Faeces  were  passed 
unconsciously  and  involuntarily.  The  penis  presented  no  turgidity. 
The  skin  of  the  lower  limbs  felt  dry  and  warm,  and  presented 
patches  of  redness  as  well  as  a  sore  on  the  right  heel :  scratching 
it  caused  bright  hypertemic  lines. 


72  SURGERY   OF   THE   SPINAL    CORD. 

The  surface  temperature  was  taken  on  several  occasions,  with 
the  following  results  : — 

Difference  in 
favour  of  thigh. 

Dec.  21. — Front  of  thigh 86.5°  )  _       o 

Front  of  upper  arm        ......  90.6°  ) 

(Axillary 97-2°) 

Dec.  22. — Front  of  thigh 87.8°  )  _       o 

Front  of  upper  arm 88.8° 

(Axillary 98°) 

Dec.  23. — Front  of  thigh  (an  hour  after  using  battery)  .  91.6° 


+  4-9 
Front  of  upper  arm        ......     86.7°  ) 

(Axillary        ........  97.6°) 

Dec.  27. — Front  of  thigh  (before  using  battery)     .         .         .  84.9°^ 

Front  of  thigh  (immediately  after  using  battery)  .  83. 6°  ] —  4. 5 

Front  of  upper  arm        .         .         .         .         .         .  89. 4°  J 

(Axillary 97^) 

Jan.    8. — Front  of  thigh  (before  using  battery)    .         .         .  86.4°  ) 

Front  of  thigh  (immediately  after  battery)    .         .  83.9°  >  -3.6" 

Front  of  upper  arm        ......  90°     ) 

(Axillary 97.4°) 

During  his  stay  in  hospital  this  patient  never  presented  any 
changes  of  importance.  His  axillary  temperature  was  through- 
out slightly  subnormal.  One  other  point  is  worthy  of  notice  ;  his 
optic  discs  were  carefully  examined  on  several  occasions,  but  re- 
vealed no  abnormality. 

The  treatment  consisted  in  faradisation  of  the  lower  limbs,  and 
washing  out  the  bladder  daily  with  a  solution  of  boracic  acid. 

On  February  2,  1889,  he  was  discharged  as  incurable. 


Case  2  7. — Fracture-dislocation  of  tenth  dorsal  vertebra. 

L.  J.,  a  collier,  aged  thirty,  was  admitted  on  December  8, 
1888,  to  Mr.  Whitehead's  wards.  Shortly  before  admission  he 
had  been  at  work  in  a  coal-pit,  when  a  mass  of  rock,  weighing 
nine  or  ten  cwts.,  fell,  so  that  a  part  of  it  struck  him  in  the 
"  middle  of  his  back."     He  immediately  sank  down  quite  helpless. 

On  admission,  he  presented  some  swelling  about  the  eleventh 
dorsal  vertebra,  and  the  lumbar  concavity  appeared  to  begin  too 
soon.  On  the  following  day,  extension  was  made,  under  chloro- 
form, by  jack-towels  round  the  waist  and  thighs,  the  spine  being 
manipulated  at  the  same  time,  and  the  deformity  was  said  to 
have  been  thereby  reduced. 

I  saw  him  for  the  first  time  on  December  1 1 .     He  had  then 


INJURIES   TO   THE   DORSAL    REGION. 


7: 


prominence  of  the  eleventh  dorsal  spine,  with  a  depression  above 
it,  and  some  swelling  in  the  lumbar  region.  Crepitus  could  not 
be  obtained.  Any  movement  of  the  lower  limbs  caused  much 
pain,  but  no  pain  resulted  from  jarring  the  spine  vertically.  The 
lower  limbs  were  absolutely  paralysed,  the  trunk  and  upper  limbs 
being  normal.  The  plantar  and  cremasteric  reflexes  and  the 
knee-jerk  could  not  be  elicited. 

Below  the  limits  of  the  distribution  of  the  eleventh  dorsal  nerve 
there  was  partial  anaesthesia ;  but  vague  sensation  extended  rather 
more  than  a  hand's-breadth  beneath  this  point,  complete  anaes- 
thesia only  beginning  a  little  below  Poupart's  ligament.  The  penis 
and  scrotum  were  anaesthetic,  and  the  passage  of  a  catheter  was 
not  felt  until  the  moment  of  its  entrance  into  the  bladder.  The 
urine  had  been  retained  and  the  bowels  unopened  since  the  acci- 
dent. The  penis  presented  no  turgidity.  The  skin  of  the  lower 
limbs  felt  dry  and  cool. 

The  surface  temperatures  were  as  follows : — 


Dec.  21. — Front  of  thigh     . 
Front  of  upper  arm 
(Axillary  temperature 

Dec.  24. — Front  of  thigh     . 
Front  of  upper  arm 
(Axillary  temperature 

Jan.  16. — Front  of  thigh 

Front  of  upper  arm 
(Axillary  temperature 

Apr.  16. — Front  of  thigh     . 
;  Front  of  arm 
(Axillary 


Difference  in  favour 
of  lower  limb. 

91°      \ 

91.8°  i 

-0.8° 

99-4°) 

92"     J 

90°    s 

+  2.0" 

97.6°) 

86.2°  ) 
87.8°  i 

-1.6° 

98.6°) 

93-2°  I 
94.8-  i 

-1.6 

99-4°) 

The  bowels  continued  to  be  very  constipated,  and  cystitis 
shortly  supervened,  for  which  the  bladder  was  daily  washed  out 
with  boracic  acid  lotion. 

On  February  i,  1889,  his  condition  was  again  carefully 
examined.  The  lower  limbs  were  much  wasted,  and  still  com- 
pletely paralysed  and  anaesthetic.  The  plantar  and  cremasteric 
reflexes  and  the  knee-jerks  could  not  be  obtained.  The  upper 
boundary  of  the  angesthesia  corresponded  accurately  to  the  lower 
limit  of  the  distribution  of  the  last  dorsal  nerve.  After  washing 
out  and  emptying  the  bladder,  urine  was  retained  for  some  two 
hours,  after  which  incontinence  came  on,  remaining  until  the 
bladder  was  again  emptied  on  the  following  day.  This  incon- 
tinence consisted  in  a  continuous  dribbling  with  an  occasional 
forcible  and  copious  discharge.      Even  when  the  bladder  was  full, 


74  SURGERY    OF    THE   SPINAL   CORD. 

no  dulness  could  be  obtained  on  percussion  above  the  pubes. 
The  patient  was  conscious  of  the  distension  of  his  bladder  by  the 
lotion.  The  urine  itself  remained  very  foul  and  purulent.  The 
temperature  was  irregular,  being  frequently  above  normal.  Bed- 
sores had  formed  on  the  left  buttock  and  on  both  knees  and  heels. 
Scratching  of  the  skin  of  the  thighs,  which  was  very  dry,  caused 
marked  hyperaemic  lines,  lasting  for  some  minutes.  The  fundi  of 
the  eyes  were  normal. 

On  April  i6,  1889,  when  the  last  note  was  taken,  the  man's 
condition  was  practically  unchanged.  The  lower  limbs  had  wasted 
greatly,  and  were  rigid  and  extended,  with  the  toes  pointed.  The 
skin  was  rough  and  dry,  with  ulcers  at  various  places.  The  super- 
ficial and  deep  reflexes  were  still  absent  below  the  injured  region. 
The  bladder  had  gradually  acquired  the  power  of  retaining  urine 
for  a  longer  period,  amounting  to  about  four  hours  after  catheter- 
isation,  and  the  urine  was  less  foul  and  contained  less  pus. 


Case  28. — Dislocation  of  eleventh  dorsal  vertclra. 

J.  E,.,  a  collier,  aged  twenty-two,  was  admitted  under  Mr. 
Jones's  care  on  July  19,  1888.  A  week  previously  he  had  been 
working  in  a  mine,  when  some  coal  fell  upon  his  head,  throwing 
him* forwards,  after  which  a  further  quantity  of  coal  came  down 
on  to  his  back.  He  did  not  lose  consciousness  or  present  any 
signs  of  cerebral  concussion,  but  found  at  once  that  he  could  not 
move  his  legs. 

On  admission,  he  complained  of  pain  in  the  lumbar  region  of 
the  spine,  and  there  was  found  a  diffuse  prominence,  most  marked 
over  the  last  dorsal  spine,  but  obscured  by  effusion  of  blood,  which 
extended  somewhat  higher  than  this  point.  No  pain  was  caused 
by  vertical  jarring  of  the  spine.  The  lower  limbs  were  completely 
paralysed,  but  the  abdominal,  thoracic,  and  upper  limb  muscles 
were  unaffected.  The  plantar,  cremasteric,  abdominal,  and  epigastric 
reflexes  were  all  absent,  as  was  the  knee-jerk.  Anaesthesia  had 
a  well-defined  border,  corresponding  accurately  throughout  to  the 
lower  limit  of  the  distribution  of  the  last  dorsal  nerve,  and  there 
was  no  hypersesthesia ;  those  branches  of  the  last  dorsal  nerve 
which  descend  on  to  the  upper  part  of  the  gluteal  region  retained 
their  sensation,  but  the  rest  of  this  area  was  anesthetic. 

The  urine  was  retained,  fulness  of  the  bladder  causing  pain, 
and  the  urine  contained  pus  and  phosphates  (the   patient   had 


IXJUllIES    TO    THE    DORSAL    REGION.  75 

previously  been  suffering  from  gonorrhoea) ;  but  no  sugar  and 
very  little  albumin.  The  bowels  were  very  constipated.  On  the 
feet  were  patches  of  redness,  and  the  skin  about  the  perineum 
and  penis  was  red  and  rather  raw.  The  penis  itself  was  turgid. 
The  slightest  scratch  of  the  lower  limbs  produced  a  bright  hyper- 
asmic  line,  lasting  for  several  minutes.  The  temperature  was 
normal. 

Treatment  consisted  in  periodic  evacuation  and  washing  out  of 
the  bladder. 

Two  days  later  the  patient  was  put  under  chloroform,  and  an 
attempt  made  to  reduce  the  spinal  dislocation.  Jack-towels  being 
placed  round  the  thighs,  the  thorax  was  firmly  held,  and  extension 
made  upon  the  lower  limbs,  when  a  distinct  jerk  was  felt  at  the 
site  of  the  fracture,  the  prominence  of  the  twelfth  dorsal  spine 
becoming  less  marked.  On  relaxing  the  extension,  the  deformity 
returned  as  before,  and  the  process  was  repeated  two  or  three 
times,  the  pelvis  being  also  carried  backwards  so  as  to  increase 
the  deficient  lumbar  convexity.  Permanent  reduction  was,  how- 
ever, found  to  be  impossible,  and  a  plaster  of  Paris  jacket  was 
then  applied,  the  back  being  partially  supported  by  a  towel  under 
the  lumbar  region  until  the  plaster  had  set. 

On  July  31,  there  being  no  improvement,  the  jacket  was 
removed  with  the  view  of  trephining  the  spine ;  but  there  being 
now  no  deformity,  the  operation  was  not  performed,  and  a  felt 
jacket  was  reapplied. 

From  this  point  the  case  presents  little  of  interest.  The 
nervous  symptoms  did  not  improve,  the  only  change  being  that 
in  September  the  patient  complained  a  few  times  of  shooting 
pains  in  the  lower  limbs.  When  the  jacket  was  removed  six 
weeks  after  its  reapplication,  the  twelfth  dorsal  spine  was  as 
prominent  as  ever,  having  a  depression  above  it.  Turgidity  of 
the  penis  passed  off  a  few  days  after  admission.  The  urine  con- 
tinued to  be  very  foul,  purulent,  and  ammoniacal,  and  on  one 
occasion  a  phosphatic  concretion  about  the  size  of  a  hemp-seed 
came  away  in  the  eye  of  the  catheter.  Gradual  emaciation 
ensued,  and  on  October  25,  1888,  the  man  was  sent  home  as 
incurable. 

The  first  point  to  be  noticed  is  that  in  these,  as  in  other  pub- 
lished cases  of  spinal  injuries,  the  level  of  the  upper  border  of 
the  anaesthesia  is  usually  somewhat  below  the  level  of  the  lesion. 
Then,  in  Case  23,  where,  from  the  prominence  of  the  sixth  dorsal 
spine,  we  probably  had  a  dislocation  forwards  of  the  fifth  dorsal 


76  SDRGEEY    OF    THE    SPINAL    CORD. 

vertebra,  the  anaesthesia  only  affected  the  intercostal  nerves  as 
high  as  the  sixth  (inclusive),  and  in  Case  24,  although  the  sixth 
dorsal  vertebra  was  displaced  backwards  and  divided  the  cord,  the 
anaesthesia  did  not  extend  above  the  eighth  intercostal  nerve. 

Similarly,  it  will  be  found  throughout  that  the  upper  level  of 
the  anaesthesia  is  generally  somewhat  below  the  area  of  distribu- 
tion of  the  nerve  trunk  corresponding  to  the  injured  vertebra, 
the  only  exception  being  Case  25.  But  as  it  is  practically 
not  possible  to  differentiate  the  action  of  each  intercostal  muscle, 
we  can  only  assume  that  the  paralysis  probably  reaches  to  the 
Same  level  as  the  anaesthesia,  and  thus  we  conclude  that  the 
superior  limit  of  the  isolation  of  the  spinal  nervous  system  is 
generally  rather  lower  than  might  at  the  first  glance  be  expected. 
This  relationship  is  best  represented  by  a  table  giving  the  pro- 
bable level  of  the  crush  of  the  cord,  and  the  actual  upper  limit 
of  paralysis  and  ansesthesia.  The  probable  level  of  the  lesion  is, 
in  the  absence  of  post-mortem  data,  derived  from  the  marked 
prominence  of  a  spinous  process,  such  prominence  being  taken  to 
indicate  a  dislocation  forwards  of  the  body  of  the  vertebra  imme- 
diately above  that  of  which  the  spine  projects.  We  thus  obtain 
the  following  results  :  ^ — 

Probable  Site  of  Lesion  relatively  Highest  Nerve  whose  Functions 

Case  to  the  Vertebra.  are  Lost. 


23.  Junction  of  fifth  and  sixth  dorsal. 

24.  Sixth  dorsal.  ..... 

25.  Seventh  dorsal 

26.  Junction  of  ninth  and  tenth  dorsal. 

27.  Junction  of  tenth  and  eleventh  dorsal. 


Sixth  intercostal. 
Eighth  intercostal. 
Seventh  intercostal. 
Twelfth  dorsal. 
First  lumbar. 


28.     Junction  of  eleventh  and  twelfth  dorsal.  .     First  lumbar. 

In  order  further  to  ascertain  this  relationship,  I  have  taken  from 
Gurlt's  analysis  ^  all  those  fatal  cases  of  fracture  in  the  dorsal  region 
in  which  there  is  fairly  definite  information  as  to  the  exact  site 
of  the  injury  and  the  upper  level  of  the  paralysis  and  anaesthesia. 
Few  of  the  cases  are  explicit  upon  this  point,  but  these  few  I  have 
arranged  in  a  Table.  The  first  column  shows  the  probable  exact 
site  (relatively  to  the  vertebrae)  of  the  crush  of  the  spinal  cord  ; 
the  second  gives  the  level  to  which  symptoms  are  said  to  have 
extended  ;  and  the  third,  the  nerve  which  would  from  this  datum 
appear  to  have  been  the  highest  to  be  affected. 

^  Case  22  is  omitted,  as  the  symptoms  were  too  indefinite  for  accurate  localisation. 
^  Uandbuch  der  Lehre  von  den  Knochenbrilchen,  vol.  ii. 


INJORIES    TO    THE   DORSAL   REGION. 


11 


JJq_ 

Site  of  Lesion  of  Cord  Rela- 

Highest Level  of  Paralysis  or 

Highest  Paralysed 

tively  to  the  Vertebra. 

Aiisesthesia. 

Nerve. 

tl. 

Second  dorsal. 

Third  rib. 

Third  dorsal. 

2. 

Third  dorsal. 

Seventh  rib. 

Seventh  dorsal. 

3- 

Third-fourth  dorsal. 

Umbilicus. 

Eleventh  dorsal. 

+4. 

Fourth  dorsal. 

Sixth  dorsal  vertebra. 

Sixth  dorsal. 

+5- 

Fourth-fifth  dorsal. 

Epigastrium. 

Sixth    or     seventh 
dorsal. 

t6. 

Fourth  dorsal. 

Epigastrium. 

Sixth    or     seventh 
dorsal. 

t7. 

Fifth-sixth  dorsal. 

"  As  far  as  the  false  ribs." 

Seventh  dorsal. 

*8. 

Fourth-seventh  dorsal. 

Nipples, 

Fourth  dorsal. 

t9. 

Sixth  dorsal. 

Two  inches  above  umbilicus. 

Eighth     or     ninth 
dorsal. 

tio. 

Seventh  dorsal. 

Umbilicus  and  eighth  dorsal 

Eighth  or  eleventh 

vertebra. 

dorsal  (?). 

tii. 

Seventh-eighth  dorsal. 

Pit  of  stomach. 

Ninth  dorsal  (?). 

tl2. 

Eighth  dorsal. 

Three  fingers'   breadth  above 
umbilicus. 

Ninth  dorsal. 

*i3. 

Ninth  dorsal. 

Two   inches   above   umbilicus 
and  twelfth  rib. 

Ninth  dorsal. 

ti4. 

Ninth-tenth  dorsal. 

One  inch  above  umbilicus. 

Tenth  dorsal. 

ti5- 

Ninth-tenth  dorsal. 

Umbilicus. 

Eleventh  dorsal. 

1 6. 

Ninth-tenth  dorsal. 

Four  inches  above  umbilicus. 

Eighth  dorsal. 

+  17. 

Upper  eleventh  dorsal. 

Half  inch  below  umbilicus. 

Twelfth  dorsal. 

+i8. 

Whole  eleventh  dorsal. 

Last  false  rib. 

Twelfth  dorsal. 

*I9. 

Middle  eleventh  dorsal. 

Umbilicus. 

Eleventh  dorsal. 

*20. 

Eleventh-twelfth     dor- 
sal. 
Twelfth  dorsal. 

Umbilicus. 

Eleventh  dorsal. 

+21. 

Anterior  superiorspineof  ilium. 

Second  lumbar. 

+22. 

Middle  twelfth  dorsal. 

A  nterior  superior  spine  of  ilium. 

Second  lumbar. 

23. 

Twelfth  dorsal. 

Paralysis  of  lower  limbs,  anaes- 

Motor, second  lum- 

thesia below  knees. 

bar  sensory,  fifth 
lumbar. 

+24. 

Twelfth  dorsal. 

Paral3'sis   and    anaesthesia  of 
lower  limbs. 

Second  lumbar. 

25- 

Eleventh-twelfth  dorsal. 

No    paralytiis,    anaesthesia   of 
sciatic  nerves. 

Fifth  lumbar. 

26. 

Eleventh  dorsal  to  first 

Paralysis  of  lower  limbs,  anaes- 

Fourth lumbar  (?). 

lumbar. 

thesia  from  middle  of  thigh 
and  gluteal  fold. 

27. 

Twelfth  dorsal. 

Inguinal  region. 

Third  lumbar  (?), 

Looking  now  at  the  above  Table,  we  find  that  the  cases  can  be 
arranged  in  three  groups,  viz. : — 

Group  A.  (marked  *)  consists  of  four  cases  (8,  13,  19,  and 
20),  in  which  the  nervous  symptoms  extend  as  high  as  the 
vertebral  lesion.  To  these  may  be  added  No.  25  of  my  own 
cases,  giving  five  instances  out  of  thirty-three. 

Group  B.  (marked  t)  consists  of  sixteen  cases,  in  which  the 
nervous  phenomena  find  their  highest  level  at  a  distance, 
generally  equal  to  the  area  of  distribution  of  about  two  inter- 
costal nerves,  below  the  trunk  coming  out  under  the  displaced 
vertebra.  Adding  to  these  five  of  my  own  cases,  we  find  in 
this  group  twenty-one  out  of  thirty-three  cases. 


yS  SURGERY   OF   THE   SPINAL   CORD. 

Group  C.  (Cases  2,  3,  23,  25,  26,  27,  and  16  from  Gurlt) 
contains  the  remaining  seven  cases,  in  the  first  six  of  which  the 
paralysis  was  a  considerable  distance  below  the  vertebral  lesion, 
whereas  in  the  last  it  extended  above  this  level. 

The  reason  of  this  distribution  will  be  obvious  upon  looking 
at  the  diagram  given  by  Dr.  Gowers  in  his  work  on  "  The  Diag- 
nosis of  the  Diseases  of  the  Spinal  Cord."  If  we  have  a  dis- 
location, say,  between  the  fourth  and  Jifth  dorsal  vertebrae,  we 
have  a  crush  of  the  spinal  cord  about  the  level  of  origin  of  the 
sixth  dorsal  nerve,  with  possible  injury  to  the  fourth  and  fifth 
roots,  which  here  lie  beside  the  cord.  But  the  cord  is  a  much 
more  fragile  structure  than  the  roots,  and  is  from  its  size  and 
position  more  exposed  to  injury,  so  that  it  is  constantly  damaged 
in  cases  in  which  the  roots  remain  intact.  Hence  we  must 
expect  the  level  of  the  paralysis  to  be  lower  than  that  of  the 
vertebral  lesion  by  just  so  much  distance  as  is  occupied  by  the 
intraspinal  course  of  the  nerve-roots  at  the  site  of  injury.  In 
this  way  we  can  explain  the  distribution  of  the  symptoms  in  the 
large  number  of  cases  forming  Group  B.  In  doing  so,  it  must 
be  remembered  that  the  level  of  origin  of  the  nerve-roots  rela- 
tively to  the  vertebrae  varies  within  considerable  limits,  extend- 
ing even,  it  may  be,  to  more  than  the  depth  of  an  entire  vertebra, 
a  point  clearly  illustrated  by  Mr.  Reid's  excellent  diagram.^ 

Should  the  crush  be  very  severe,  we  may  also  have  the  roots 
injured,  when  we  get  the  exceptional  condition  of  Group  A. 
Thus,  in  my  own  Case  25,  which  was  of  this  nature,  the  spinal 
injury  was  so  severe  that  "  the  spine  was  movable  in  all  direc- 
tions;" and  in  Case  16  of  those  quoted  from  Gurlt,  we  are  distinctly 
told  that  the  roots  of  the  ninth  and  tenth  nerves  were  destroyed. 

In  Group  C.  are  two  cases  (2  and  3)  which  I  find  unintelli- 
gible. In  both,  the  cord  was  said  to  be  torn  across  at  the  site 
of  the  fracture,  and  in  the  second  of  them  the  ends  were  sepa- 
rated by  more  than  an  inch.  Under  these  circumstances,  we 
can  hardly  accept  as  reliable  the  statements  that  anassthesia  only 
commenced  far  below  the  level  of  the  lesion.  Cases  23,  25,  26, 
and  27  really  belong  to  the  same  category  as  those  of  Group  B. ; 
they  are  all  injuries  about  the  twelfth  dorsal  vertebra,  to  which 
correspond  the  origins  of  the  second  and  subsequent  lumbar  j 
nerves  and  the  commencement  of  the  cauda  equina,  and  the  ' 
apparently  very  low  boundary  of  the  anassthesia  is  a  result  of  the 
long  intraspinal  course  of  the  nerves  in  this  region. 

To  sum  up,  we  find  that,  omitting  the  two  doubtful  cases  and 
^  Journal  of  Anatomy  and  Physiology,  1889,  vol,  xxiii.  p.  341. 


INJURIES    TO    THE   DORSAL   REGION.  79 

Case  16,  which  will  be  referred  to  presently,  we  have  thirty 
injuries  in  the  dorsal  region,  in  five  of  which  both  the  cord 
and  the  roots  were  crushed,  so  that  the  level  of  the  paralysis  and 
anaesthesia  corresponded  to  that  of  the  bony  lesion  ;  whereas  in 
twenty-five  cases,  the  cord  only  being  crushed,  the  limit  of  the 
nervous  symptoms  lay  correspondingly  lower. 

The  point  may  appear  a  trivial  one,  but  it  has  really  a  most 
important  practical  bearing  in  at  least  two  directions. 

1.  There  seems  a  strong  probability  that  the  operation  of 
"  trephining "  the  spine  may  shortly  become  not  infrequent,  if 
not  for  injuries,  at  any  rate  for  certain  other  pressure  lesions  of 
the  cord.  It  is  thus  of  the  first  consequence  to  recognise  and  to 
recollect  that  the  seat  of  compression  will,  in  the  great  majority 
of  cases,  be  higher  than  that  of  the  anaesthesia  by  the  length  of 
the  intra-vertebral  course  of  the  implicated  nerves. 

In  his  exhaustive  paper  upon  the  surgery  of  tumours  of  the 
spinal  cord,^  Mr.  Victor  Horsley  refers  in  some  detail  to  this 
subject,  and  comes  to  the  conclusion  that  "  the  difference  between 
the  position  of  the  growth  and  the  localisation  of  the  pain  is 
clearly  due  to  the  anatomical  relations  of  the  nerve  organs  and 
roots  to  the  vertebrae,  and  something  more,  viz.,  the  as  yet  (in 
the  human  being)  imperfectly  known  course  of  the  fibres  in  the 
spinal  cord."  So  far  as  spinal  injuries  throw  any  light  upon  the 
subject,  there  does  not,  however,  appear  to  be  any  necessity,  in 
the  cases  composing  Group  B.,  to  assume  any  other  factor  in  the 
determination  of  the  level  of  the  lesion  than  the  obvious  ana- 
tomical conditions  already  referred  to,  varying  as  Keid  has  shown 
these  conditions  to  be. 

2.  Another  important  practical  point  which  is  brought  out 
by  the  above  facts  is  that  where  (as  in  cases  of  injury)  the  site  of 
the  lesion  relatively  to  the  spine  is  already  known,  and  where  the 
anaesthesia  extends  as  high  as  this  level,  then  we  are  in  the  pre- 
sence of  a  lesion  sufiiciently  severe  to  have  compressed  both  the 
cord  and  its  roots, — one,  therefore,  in  which  any  operation  will 
probably  be  utterly  hopeless. 

There  remain  for  consideration  a  few  cases  in  which  the  upper 
limit  of  the  anaesthesia  is  found  to  be  considerably  below  that  of 
the  lesion — much  lower  than  can  be  accounted  for  by  the  intra- 
vertebral  course  of  the  nerves.  Two  cases  of  this  nature  have  been 
recorded  above  on  pp.  26  and  47,  and  these  two  cases  probably 
provide  the  explanation  of  the  phenomenon.  In  one  of  them 
(Case  16)  we  had  a  central  heemorrhage  in  the  lower  cervical 
^  Med.  Chir.  Trans.,  vol.  Ixxi.  p.  413.    ^ 


8o  SORGERY   OF   THE   SPINAL   CORD. 

region,  and  the  complete  ansesthesia,  which  was  transient  merely, 
only  extended  as  high  as  the  knees,  thence  shading  gradually  to  "  as 
high  as  a  line  drawn  round  the  abdomen  about  two  inches  below 
the  umbilicus."  This  being  one  of  my  earlier  cases,  I  am  by 
no  means  certain  that  the  expression  "  as  high  as  the  knees " 
correctly  represents  the  limits  of  the  anassthetic  region,  which 
probably  extended  much  higher  on  the  posterior  aspect  of  the 
limbs  (infra,  pp.  126,  &c.) ;  but  the  important  points  are  that 
the  upper  level  was  far  below  that  of  the  lesion,  and  that  the 
boundary  was  very  ill-defined.  Again,  in  Case  1 1 ,  we  find  that 
the  lesion  was  situated  about  the  point  of  origin  of  the  sixth 
cervical  nerves,  but  that  complete  ansesthesia  extended  only  as 
high  as  the  sixth  dorsal  nerves ;  and  that  again  the  boundary  was 
a  very  ill-defined  one,  some  impairment  of  sensation  extending 
upwards  to  the  lower  cervical  nerves.  In  both  cases  there  was 
ample  evidence  that  the  functions  of  the  cord  were  not  entirely 
destroyed  by  the  lesion,  and  that  some  of  its  conducting  fibres 
had  escaped  complete  compression. 

But  in  the  first  case,  it  is  certain  that^the  lesion  was  a  central 
hasmorrhage ;  and  in  the  second,  there  was  no  persistent  bony 
displacement,  so  that  haemorrhage  was  the  sole  cause  of  symptoms, 
and   haemorrhage   is   always    most   severe   in   the  centre    of  the. 
cord.       It  will    therefore   follow  that    in    both   cases   the    morel 
peripheral  of  the  descending  fibres  would  be  less  subject  to  com-/ 
pression  than  those  more  centrally   situated ;   and  if  the  sensory\ 
fibres  for  the  lower  parts  of  the  body  be  the  more  centrally  situated, 
these  would  chiefly  suffer.      It  would  appear  that  this  is  the  case, 
and  that  in  these  two  instances  the  eccentric  pressure  was  in- 
sufficient to  paralyse  the  most  peripheral  fibres — that  is,  those 
which  leave  the  cord  highest.     This  view  will  explain  the  very 
gradual  increase  in  the  anaesthesia  from  above  downwards,  and 
the  suggested  arrangement  is  also  obviously  probable,  inasmuch 
as,  if  the  higher  fibres  were  situated   centrally  to  those  which 
leave  the  cord  below  them,  they  would  require  to  cross  the  latter 
in  order  to  reach  their  point  of  exit. 

Such  an  explanation  appeared  to  me  adequate  to  explain  the 
phenomena,  until  I  became  aware,  from  reading  Mr.  Horsley's 
paper  above  referred  to,  that  the  same  tendency  to  implicate 
the  lowest  sensory  nerves  first  is  observed  also  in  the  case  of 
tumours  whose  pressure  upon  the  cord  is  concentric,  and  which 
would  therefore,  in  accordance  with  the  above  theory,  appear 
likely  to  produce  at  first  an  exactly  opposite  condition.  In 
the  absence  of  any  other  explanation,  however,  I  am  still  inclined 


INJURIES    TO    THE   DORSAL    REGION.  51 

to  regard  the  theory  as  probably  correct.  The  central  parts  of 
the  cord  are  the  most  vascular,  and  the  nerve-fibres  are  here 
least  protected  by  the  intramedullary  connective  tissue,  so  that 
even  in  the  case  of  a  concentric  pressure  lesion,  we  can  under- 
stand that  they  may  be  the  most  susceptible  both  to  the  direct 
effects  of  pressure  and  to  the  indirect  results  of  any  localised 
congestion  which  may  be,  and  probably  is,  created  thereby^ 

Mr.  Horsley  also  calls  attention  to  the  fact  that,  in  the  case 
of  tumours,  the  direction  of  invasion  of  paralysis  is  the  reverse  of 
that  of  anaesthesia  (and  pain),  being  from  abov^e  downwards.  This 
same  tendency  is  illustrated  in  some  of  the  above  cases,  especially 
in  Case  21  (p.  5  9),  in  which,  during  recovery  from  a  lesion 
external  to  the  cord,  power  of  voluntary  movement  was  partially 
restored  in  the  lower  limbs  first,  beginning  at  the  ankle,  and  in 
the  case  of  the  upper  limbs  the  paralysis  improved  in  the  hands 
only.  So  also  the  majority  of  the  cases  of  haematomyelia  pre- 
sent, during  recovery,  a  return  of  power  from  below  upwards. 
Possibly,  therefore,  the  motor  fibres  are  laterally  arranged  in  a 
manner  exactly  opposite  to  that  of  those  for  sensory  conduction, 
but  the  present  evidence  upon  this  point  is  even  more  scanty  in 
the  case  of  the  former  than  in  that  of  the  latter. 

Finally,  it  will  be  obvious  that  if,  in  a  case  of  fracture  of  the 
spine,  either  myelitis  or  haemorrhage  extend  above  the  level  of 
the  bony  lesion,  the  nerve-symptoms  will  also  extend  to  a  corre- 
sponding degree, — a  condition  illustrated  by  Nos.  13  and  14  of 
my  own  cases,  and  by  No.  1 6  of  those  quoted  from  Gurlt. 

The  above  records  of  the  surface  temperatures  in  the  paralysed 
and  non-paralysed  regions  respectively  are  too  few  in  number  for 
safe  generalisation,  and  they  are  here  introduced  mainly  as  afford- 
ing material  which  may  be  useful  in  assisting  future  research,  it 
being  only  by  collective  investigation  that  we  can  obtain  satis- 
factory conclusions  upon  such  a  point  in  cases  of  such  comparative 
infrequency  as  spinal  injuries. 

It  would,  however,  appear  that,  in  a  complete  transverse  injury 
of  the  cord,  we  have  produced,  even  from  an  early  period,  some 
contraction  of  the  vessels  of  the  paralysed  regions — at  least  this 
is  so  where  the  injury  is  below  the  cervical  region.  Correspond- 
ing with  the  lower  temperatures  thus  observed  is  the  frequently 
noted  dryness  of  the  paralysed  limbs,  resulting  from  a  deficient 
secretion  of  sweat,  and  giving  to  the  hand  a  deceptive  sensation 
of  warmth. 

It    is   even    more    obvious   that    when   the    spinal   vaso-motor 

P 


82  SURGERY    OF    THE   SPINAL    CORD. 

centres  are  left  in  entire  control  of  the  vascular  walls,  they  mani- 
fest an  extreme  sensibility  to  external  impressions. 

Thus  it  has  been  constantly  observed  in  the  preceding  cases,  as 
well  as  in  those  which  will  follow,  that  slight  irritation  of  para- 
lysed parts,  as  by  scratching,  produces  a  temporary  active  con- 
gestion of  the  skin.  It  would  also  appear  from  the  results 
obtained  in  Cases  22  and  26  that  the  immediate  effect  of  the 
application  of  the  electric  current  is  a  contraction  of  the  vessels, 
but  that  after  a  lapse  of  some  little  time  this  contraction  is 
followed  by  a  dilatation,  I  may  add  that  care  was  taken  in  all 
these  observations  to  equalise  the  conditions  of  exposure  of  the 
parts  whose  temperature  was  to  be  tested,  and  that  neither  the 
uncovering  nor  the  wetting  of  the  skin  which  accompanied  the 
use  of  the  galvanic  battery  explains  the  varying  temperatures 
which  resulted. 

The  importance  of  this  abnormal  mobility  of  the  blood-vessels, 
and  of  their  tendency  to  congestion  upon  slight  irritation,  in  the 
causation  of  "trophic"  lesions,  is  perfectly  obvious,  and  there  can 
be  little  doubt  that  similar  vascular  changes  produce  important 
effects  on  internal  organs,  as  is  illustrated  by  the  urinary  abnor- 
malities recorded  in  Chapter  I. — the  occasional  presence  of 
albumin,  of  blood,  of  excess  of  urea,  &c.,  and  of  a  compound 
capable  of  rapidly  decolourising  Fehling's  solution. 


CHAPTER  IV. 

INJURIES   TO   THE    CAUDA   EQUINA. 

Although  the  subject  of  the  present  chapter  is  but  a  portion  of 
that  to  be  considered  under  the  head  of  injuries  to  the  lumbo- 
sacral region  of  the  spinal  cord,  it  would  appear  convenient  to 
regard  apart  a  few  instances  of  the  commonest  result  of  an  incom- 
plete crush  of  the  cauda  equina,  and  I  have  therefore  reprinted 
almost  verbally  a  paper  which  appeared  in  "  Brain  "  in  January 
1888,  to  the  subject-matter  of  which  we  can  refer  back  in  con- 
sidering other  injuries  of  the  lower  portion  of  the  spinal  cord  and 
its  nerve- roots. 

The  series  of  cases  upon  which  are  based  the  conclusions  drawn 
in  the  present  chapter  appear  to  form  a  clinical  picture  the 
import  of  which  has  not  hitherto  been  fully  recognised,  although 
its  features  are  sufficiently  marked,  and  the  symptoms  described 
have  been  noted  by  more  than  one  observer.  They  present 
instances  of  very  different  lesions,  all  of  which,  however,  agree  in 
the  production  of  pressure  on  the  cauda  equina  ;  and  although  they 
are  not  all  injuries,  it  has  appeared  advisable  to  place,  side  by  side 
with  traumatic  cases,  those  due  to  other  causes,  but  resembling  them 
in  the  locality  of  the  lesion  and  in  the  nature  of  the  symptoms. 

I  shall,  in  considering  these  cases,  first  relate  their  clinica, 
histories,  drawing  attention  to  the  salient  points  of  each,  and 
shall  then  proceed  to  draw  certain  conclusions,  and  to  compare 
the  facts  observed  with  the  experience  of  previous  writers. 


Case  29. — Dislocation  of  the  first  lumbar  vertebra — Compression 
of  the  cauda  equina. 

P.  S.  attended  as  an  out-patient  in  Dr.   Ross's  clinic   during 
the  month  of  June  1886,  and  was  admitted  to  the  wards  on  the 


84 


SURGERY    OF    THE   SPINAL    CORD. 


7th  of  the  following  month.  He  gave  a  history  of  having  been 
a  heavy  smoker  and  drinker,  of  an  attack  of  syphilis  twelve  years 
ago,  and  of  pneumonia  five  years  ago.  On  January  31,  1886, 
he  fell  from  a  scaffolding  and  injured  his  back.  For  five  days 
he  was  unconscious,  and  he  has  since  then  had  paralysis  of  the 
lower  limbs,  with  retention  of  urine,  requiring  the  constant  use 
of  a  catheter. 

On  examination,  he  presented  a  distinct  deformity  of  the 
lumbar  spine,  there  being  a  wide  interval  between  the  first  and 
second  spinous  processes,  with  prominence  of  the  latter.  There 
was  slight  pain  in  the  affected  region,  but  no  tenderness.  (The 
exact  position  of  the  deformity  was  verified  by  repeated  examina- 
tions by  various  gentlemen.) 

The  lower  limbs  presented  complete  paralysis  of  all  the  muscles 
below  the  knee,  and  of  the  flexors  of  the  knee,  and  there  was 
weakness,  but  not  entire  loss  of  power,  in  the  extensors  of  that 
joint.  Flexion  of  the  thigh  could  apparently  be  performed 
without  difficulty ;  the  power  of  adduction  was  slight,  and  that 
of  extension  and  abduction  almost,  but  not  quite,  entirely  lost. 
The  buttocks  and  lower  extremities  were  wasted  throughout. 
Electric  examination  of  the  affected  region  gave  contractions  with 
the  following  currents  : — 


Right  Limb. 

Left  Limb. 

Kathodal 

Anodal 

Faradic 

Kathodal 

Anodal 

Faradic 

Closure. 

Closure. 

Current. 

Closure. 

Closure. 

Current. 

Cells. 

Cells. 

Cells. 

Cells. 

Rectus 

No  effect 

No  effect 

Sartorius     . 

35 

30 

25 

20 

Vastus  externus  . 

25 

20 

25 

30 

Vastus  intern  us  . 

35 

30 

30 

30 

Gluteus  maxiinus         .  J 

^ 

Biceps         .         .         .  1 

No  contraction 

f  No  contraction 

Semimembranosus       .  t 

with  50  ceils. 

i  with  50  cells. 

Semitendinosus  .         .  ) 

J 

Adductor  longus 

Adductor  magnus 

Gracilis 

Gastrocnemius    . 

40 

40 

35 

30 

Tibialis  anticus   . 

25 

20 

25 

20 

Extensor        proprius    | 

poUicis     .         .         .\ 

Peroneus longus . 

25 

25 

30 

30 

The  knee-jerk  and  plantar  reflexes  were  absent,  but  the  cre- 
masteric reflexes  were  normal. 

Sensation  was  normal  on  the  upper  part  of  the  buttocks,  that 


INJURIES    TO    THE    CAUDA    EQUINA.  85 

is,  in  the  region  supplied  by  the  last  dorsal,  ilio-hypogastric,  and 
external  cutaneous  nerves,  and  was  little  if  at  all  diminished  on 
the  front  of  the  thighs  and  the  anterior  halves  of  their  inner  and 
outer  aspects,  or  on  the  inner  sides  of  the  legs ;  but  there  was 
complete  ansesthesia  of  the  backs  of  the  thighs,  of  that  part  of  the 
buttocks  not  included  in  the  above  limits,  of  the  outer  sides 
of  the  legs,  and  of  the  feet.  The  perineum,  the  penis,  and  the 
scrotum  were  also  quite  ansesthetic,  with  the  exception  of  the 
root  of  the  latter,  and  the  catheter  was  not  felt  in  the  urethra. 
The  patient  was,  however,  aware  when  the  bladder  was  full,  and 
when  he  wished  to  empty  the  rectum,  but  had  no  control  over 
tlie  latter,  and  could  not  feel  the  passage  of  faeces.  At  times  he 
would  have  pricking  sensations  in  the  toes  and  some  pain  in  the 
thighs. 

The  lower  limbs  presented  no  obvious  change  of  temperature. 
Since  the  accident  there  had  been  no  erections  of  the  penis.  On 
both  heels  were  bed-sores  of  large  size.  The  urine,  which  was 
retained,  was  alkaline,  containing  large  quantities  of  pus  and 
phosphates. 

The  patient  remained  under  observation  and  treatment  for  some 
time ;  but,  with  the  exception  of  amelioration  of  his  cystitis  and 
bed-sores,  underwent  no  change.  On  leaving,  he  was  instructed 
to  return,  with  a  view  to  trephining  the  spine,  but  he  has  not 
since  been  heard  of. 

The  explanation  of  the  above  case  is  sufficiently  obvious. 
There  is  sensory  paralysis  of  all  the  nerves  of  the  sacral  plexus, 
and  possibly  of  the  obturator,  but  not  of  the  anterior  crural  or 
other  lumbar  nerves :  the  perineum,  penis,  scrotum,  and  urethra, 
being  supplied  by  branches  of  the  pudic,  are  anaBSthetic,  but  the 
root  of  the  scrotum  retains  sensation  owing  to  the  presence  of 
twigs  of  the  ilio-inguinal  nerve,  which,  however,  only  descend  to 
a  very  short  distance. 

As  regards  motion,  we  find  complete  paralysis  with  the  "  reac- 
tion of  degeneration  "  of  the  muscles  supplied  by  the  nerves  of 
the  sacral  plexus.  Those  supplied  by  the  anterior  crural,  although 
presenting  the  reaction  of  degeneration,  are  only  weakened,  and 
the  adductors,  supplied  by  the  obturator,  appear  also  to  retain 
some  power. 

Again,  the  cremasteric  reflex  remains,  but  below  its  level 
reflex  action  is  lost. 


86  SURGERY    OF   THE   SPINAL    CORD. 


Case  30. — Spina  bifida — Cui'e — Cauda  equina  compressed  hy 

cicatrix. 

F.  H.  W.  has  been  several  times  admitted  into  the  Manchester 
Royal  Infirmary,  under  the  care  successively  of  Mr.  Lund,  Mr. 
Whitehead,  and  Dr.  Ross.  He  is  a  clerk  by  occupation,  is  twenty- 
four  years  of  age,  and  gives  the  following  account  of  himself.  At 
birth  he  had  a  swelling  (spina  bifida)  which  was  never  larger 
than  an  orange,  over  the  lower  part  of  the  back.  Very  soon  after 
birth  a  needle  was  thrust  into  this,  but  he  does  not  know  whether 
any  effect  ensued.  When  two  years  of  age  he  was  said  to  have 
had  a  fit,  followed  by  paralysis,  and  subsequently  wasting  of  the 
muscles  below  the  knee  on  both  sides.  He  also  states  that  there 
was  some  contraction  of  the  calf-muscles,  causing  drawing  up  of 
the  heel,  which  on  two  occasions  required  division  of  the  tendo 
Achillis,  followed  by  the  use  of  a  metal  boot.  The  deformity  was 
thus  eventually  overcome.  When  about  fifteen  years  of  age  lie 
began  to  be  troubled  by  an  ulcer  on  the  outer  side  of  the  right 
foot,  which  resisted  all  treatment,  until  in  1883  the  little  toe,  with 
its  metatarsal  bone,  was  amputated  by  Mr.  Lund.  The  wound 
thus  caused  remained  open  for  nineteen  months,  at  the  end  of 
which  time  its  upper  end  had  again  formed  an  ulcer.  This  ulcer 
still  remains,  and  is  his  chief  trouble  ;  it  improves  when  he  is 
confined  to  his  bed,  but  soon  breaks  down  again  when  he  tries  to 
move  about. 

The  condition  of  the  patient  never  varied  very  materially 
at  the  various  times,  extending  over  a  period  of  some  eighteen 
months,  during  which  he  was  under  observation,  and  he  presents 
the  following  points. 

On  the  back,  opposite  to  the  last  lumbar  or  first  sacral  vertebra, 
is  a  flattened  swelling  about  the  size  of  a  hen's  &gg,  but  of 
lenticular  shape  and  covered  with  hair.  At  its  centre  is  a  de- 
pression, into  which  he  states  that  a  stocking-needle  was  passed 
at  birth  ;  but  he  also  says  that  the  depression  was  congenital,  and 
that  the  needle  was  used  only  to  probe  its  depth.  The  swelling 
is  of  an  elastic  consistence,  and  gentle  manipulation  causes  sen- 
sations which  the  patient  says  are  pleasurable  but  indescribable. 
Firm  pressure  causes  passage  of  urine,  defecation,  and  strong 
sexual  desire ;  a  blow  upon  it  causes  some  rigidity  of  the  legs. 
Over  the  swelling  is  a  luxuriant  growth  of  hair,  which  is  also 
well-developed  on  the  lower  limbs. 

Both  the  lower  limbs  show  distinct  wasting,  which  is  moi-e 


INJURIES   TO    THE   CAUDA    EQUINA. 


^7 


marked  on  the  right  than  on  the  left  side,  the  circumferences 
being :  right  calf,  8  inches ;  left  calf,  i  i  inches ;  right  thigh, 
14-^  inches;  left  thigh,  17  inches;  while  the  right  is  half  an 
inch  shorter  than  the  left  limb.  On  the  right  side,  the  fifth  toe 
and  its  metatarsal  bone  were  removed,  and  on  the  outer  side  of 
the  foot  over  the  fourth  metatarsal  is  an  oval  ulcer  about  one 
inch  long  and  half  an  inch  wide.  The  ulcer  shows  a  clean-cut 
margin,  which  is  raised,  horny,  and  thickened,  with  slight  under- 
mining of  its  edges  and  pale  granulations  at  its  base.  Between 
the  second  and  third  toe  on  the  same  foot  was  at  one  period  a 
second  small  ulcer,  which  recovered  with  rest.  The  arch  of  the 
foot  is  exaggerated,  the  toes  pointed,  and  there  is  no  power  of 
movement  about  the  ankle-joint. 

The  lower  limbs  are  partially  paralysed,  with  weakness  and 
wasting  of  most  of  the  muscles,  and  especially  of  those  below 
the  knee,  the  leg-muscles  of  the  right  side  being  completely 
paralysed.  The  knee-jerk,  ankle-clonus,  and  plantar  reflex  are 
absent  on  both  sides ;  the  cremasteric,  abdominal,  and  epigas- 
tric reflexes  normal.  The  electric  reactions  of  the  muscles  are  as 
follows  :  — 


Right 

Side. 

Left 

Side. 

K.  C.  C. 

A.  C.  C. 

K.  C.  C. 

A.  C.  C. 

Cells.      • 

Cells. 

Cells. 

Cells. 

Sartoriua            .... 

40 

40 

35 

40 

Adductor  magnua 

25 

30 

35 

45 

Gluteus  maximns 

nil 

nil 

50 

nil 

i     Vastus  externus 

25 

40 

40 

50 

1     Vastus  internus 

45 

40 

45 

nil 

Gastrocnemius . 

45 

50 

25 

40 

Peroneus  longus 

50 

nil 

40 

35 

Tibialis  anticus 

45 

45 

40 

nil 

Hence  they  do  not  present  the  "  reaction  of  degeneration." 
^J'o  the  faradic  current  they  react  with  difficulty  on  both  sides, 
the  anterior  muscles  of  the  left  thigh  acting  most  readily,  those 
of  the  right  foot  not  at  all.  He  has  difficulty  in  walking,  being 
always  afraid  of  falling,  and  in  the  dark  he  staggers  and  has  to 
grope  his  way.  The  walk  is  characteristically  "  pseudo-tabetic," 
resembling  that  of  locomotor  ataxia  in  its  sprawling  hesitating 
character,  but  unlike  the  gait  seen  in  that  disease,  in  that  the 
toes  drop  at  each  step.  At  times,  especially  if  he  is  tired,  there 
are  slow  fibrillar  movements  of  the  muscles  of  the  rigflit  thig-h 


88 


SURGERY    OF   THE   SPINAL    CORD. 


and  gluteal  region,  with  occasional  clioreiforra  movements  of  the 
right  foot. 

As  regards  sensation,  the  patient  states  that  he  cannot  judge  of 
the  position  of  his  right  lower  limb,  and  that  the  ground  does  not 
feel  solid  under  his  feet.  At  times  the  limbs  feel  "  as  if  they  did 
not  belong  to  him,  but  were  some  distance  off."  He  occasionally 
has  pain  in  the  dorsum  of  the  right  foot,  and  in  the  knees  and 
hips,  and  intense  tickling  sensation  in  the  sole  of  the  right 
foot.  On  examination,  there  was  found  to  be  extensive  anaesthesia 
of  the  lower  limbs,  of  similar  distribution  on  both  sides.  The 
affected  area  was  not  quite  sharply  defined,  but  had  the  general 


Kio.  II.  Fig.  12. 

outline,  represented  in  the  accompanying  diagrams,  where  the 
anaesthetic  portion  is  shaded.  Commencing  above  at  the  side  of 
the  tumour  and  almost  at  its  centre,  the  boundary-line  runs  down- 
wards and  outwards,  across  the  upper  limit  of  the  gluteal  region, 
thence,  over  the  great  trochanter,  down  the  outer  side  of  the  thigh 
to  the  apex  of  the  line  leading  to  the  external  condyle ;  it  now 
tends  forward,  somewhat  to  the  front  of  the  condyle,  and  then 
down  along  the  line  of  the  fibula  for  about  half  its  length ;  after 


INJURIES   TO    THE    CAUDA    EQUINA.  89 

which  it  comes  forward  and  inward  across  the  shin,  ending  about 
the  middle  of  the  first  metatarsal  bone.  The  inner  boundary- 
commences  about  the  external  inguinal  ring,  passes  outward 
towards  Poupart's  ligament ;  thence  slightly  backwards  for  a 
short  distance  ;  again  down  the  inner  aspect  of  the  thigh  to  the 
back  of  the  internal  condyle ;  thence  down  the  inner  side  of  the 
leg,  curving  below  the  internal  malleolus,  and  running  forwards  to 
join  the  former  line  over  the  metatarsal  bone  of  the  great-toe.  It 
will  be  noted  that  the  anaesthetic  area  includes  the  gluteal  region, 
the  back  of  the  thigh,  the  back  and  part  of  the  outer  side  of  the 
leg,  and  the  whole  of  the  foot,  except  a  small  area  on  its  inner 
aspect.  Further,  the  perineum  is  included  in  its  boundaries,  being 
absolutely  anaesthetic.  The  penis  also  is  anaesthetic,  except  at  its 
extreme  root,  as  is  the  scrotum,  except  along  a  line  too  small  to 
represent  in  the  diagram,  extending  forwards  and  downwards 
from  the  external  ring  for  about  two  inches,  and  corresponding 
apparently  to  the  distribution  of  the  ileo-inguinal  nerve.  Although 
the  scrotum  is  thus  angesthetic,  testicular  sensation  on  deep  pressure 
is  normal. 

At  one  period  he  states  that  he  passed  urine  involuntarily,  and 
had  to  wear  a  bag  to  catch  it ;  but  he  can  now  retain  it,  and 
indeed  only  passes  it  with  difficulty  and  much  straining.  He 
knows  when  the  bladder  is  full.  The  bowels  are  usually  relaxed, 
and  at  times  he  has  involuntary  evacuations.  He  is  not  always 
able  to  tell  whether  he  has  or  has  not  passed  urine  or  faeces.  He 
has  sexual  sensations  and  enjoyment,  but  states  that  on  con- 
nection the  semen  is  usually  ejaculated  before  intromission,  but 
that  on  a  second  coitus  he  can  perform  the  act  as  usual.  He  says 
that  when  under  the  influence  of  drink  he  can  both  pass  his  urine 
without  difficulty  and  complete  the  sexual  act  on  the  first  attempt. 

He  is  subject  to  attacks  of  lymphangitis  and  swelling  of  the 
inguinal  glands  in  the  right  lower  limb,  which  attacks  he  believes 
to  have  a  tendency  to  monthly  periodicity,  and  to  be  brought  on 
in  many  instances  by  drinking  or  by  sexual  excitement. 

This  case  resembles  the  last  very  closely,  differing  mainly  in 
the  less  complete  paralysis  and  in  the  partial  reaction  of  degenera- 
tion replacing  the  complete  degeneration  shown  by  Case  29.  The 
distribution  of  the  angesthesia  is  similar  to  that  of  Case  29.  An 
interesting  point  is  the  retention  of  sexual  desire  and  enjoyment 
in  spite  of  the  complete  anaesthesia  of  the  penis,  and  the  evidence 
of  persistence  of  sensation  in  the  testicles,  which  derive  their 
sensory  nerves  from  a  higher  level  of  the  cord  than  does   the 

F  # 


go  SURGERY   OF   THE   SPINAL    CORD. 

scrotum.  The  paralysis  is  again  seen  to  affect  mainly  the  branches 
of  the  sciatic,  gluteal,  and  pudic  nerves,  sparing  the  anterior 
crural  and  obturator  with  the  upper  lumbar  branches.  That  the 
lesion  is  a  compression  of  the  cauda  equina  by  the  cicatrix  of  the 
spina  bifida  there  can,  I  think,  be  no  doubt.  The  trophic  lesion 
of  the  right  foot  is  interesting,  and  is  similar  to  that  seen  in  a  case 
reported  by  Mr.  Ogston  ^  of  old  spina  bifida  with  perforating  ulcer 
of  the  left  foot,  anaesthesia  of  the  outer  side  of  the  leg  and  dorsal 
and  plantar  aspects  of  the  foot,  and  diminished  faradic  contrac- 
tility of  the  muscles  of  the  foot,  all  on  the  same  side.  Indeed, 
Ogston's  case  is  clearly  of  the  same  nature  as  the  above,  differing 
only  in  that  the  cicatrix  had,  in  his  case,  involved  but  a  portion 
of  the  fibres  of  the  sciatic  of  one  side  only. 

Another  similar  case  is  reported  by  Brunner^  as  an  instance 
of  spiTia  hi/Ida  occulta.  The  patient  had  a  depression  over  the 
spine  extending  from  the  first  to  the  fifth  lumbar  vertebra, 
excessive  growth  of  hair  over  that  region,  and  a  perforating  ulcer 
on  the  outer  side  of  the  right  foot.  The  right  lower  limb  was 
wasted,  especially  below  the  knee,  and  there  was  some  loss  of 
power  in  it :  there  was  anaesthesia  of  the  sole  and  outer  side  of 
the  foot ;  the  knee-jerk  was  lost. 

Mr.  Bland  Sutton^  has  recorded  another  case  of  perforating  ulcer 
due  to  spina  bifida  occulta,  but  we  have  no  information  as  to  the 
sensory  and  motor  functions.  He  refers,  further,  to  similar  cases 
recorded  by  Recklinghausen  and  Fischer,  the  former  presenting 
a  perforating  ulcer,  the  latter,  chronic  ostitis  of  the  metatarsus, 
and  both  having  anaesthesia  of  the  feet. 

The  next  case  presents  closely  similar  symptoms  arising  from 
the  pressure  of  a  tumour  upon  the  cauda  equina. 


Case  3  i . — Tumour  of  cauda  equina. 

Joseph  Davies  was  admitted  under  the  care  of  Dr.  Ross  on 
May  12,  1882.  His  previous  history  presented  nothing  of  inte- 
rest. About  five  months  before  admission  he  began  to  suffer 
from  pains  shooting  from  the  small  of  the  back  down  the  backs 
of  the  thighs  and  legs  to  the  feet,  which  gradually  increased 
until  he  was  unable  to  bend  his  back  and  could  hardly  walk. 

On  admission,  he  complained  of  the  above  pain,  and  of  great 
pain  in  the  buttocks  when  sitting  down.      He  could  hardly  walk, 

^  Lancet,  1876,  vol.  ii.  p.  13.  *  Virchow's  Archiv,  1887,  p.  494. 

^  Lancet,  1887,  vol.  ii.  p.  4. 


INJURIES    TO    THE    CAUDA    EQUINA.  9 1 

dragging  the  legs  along  the  ground  slowly  and  with  difficulty, 
and  the  lower  limbs  were  much  wasted.  The  patellar  reaction 
was  increased  on  both  sides.  The  urine  was  retained,  and  had  to 
be  drawn  off  with  a  catheter.  Pupils  presented  no  abnormality. 
He  was  treated  with  strychnia  and  iron. 

The  notes  at  this  period  are  very  imperfect,  but  there  seems  to 
have  been  little  or  no  change  for  a  long  time.  On  July  5  he 
was  ordered  gr,  v.  doses  of  iodide  of  potassium.  On  July  I  3  it 
was  noted  that  pain  was  greatest  about  the  ankles  and  outer  sides 
of  the  feet.  There  was  no  staggering  in  the  gait,  nor  did  he 
sway  when  standing  with  the  eyes  closed,  but  the  movements  of 
the  lower  limbs  were  very  feeble,  those  of  the  gluteal  muscles 
being  especially  so.  The  plantar  and  cremasteric  reflexes  were 
well  marked,  but  the  gluteal  was  sluggish.  The  patellar  tendon 
reaction  was  lively  (?  exaggerated)  on  both  sides.  On  both  sides 
the  muscles  of  the  lower  limbs  were  markedly  atrophied,  and, 
with  the  exception  of  the  gluteus  maximus  of  the  left  side,  had 
lost  their  faradic  contractility,  this  muscle  also  only  reacting  to 
strong  currents.  Analgesia  and  diminution  of  tactile  sensibility 
were  present  over  the  back  of  the  sacrum,  extending  thence  to 
the  perineum,  the  left  side  of  the  scrotum,  the  backs  of  both 
thighs,  and  down  the  calves  in  the  form  of  a  triangle,  with  the 
apex  downwards. 

Four  days  later  the  angesthetic  area  was  found  to  have  extended 
so  as  to  involve  the  buttocks  up  to  the  level  of  distribution  of  the 
ilio-hypogastric  nerves,  the  backs  of  the  thighs,  and  the  bulk  of 
the  leg,  omitting,  however,  the  front  of  the  knee-joint,  inner  border 
of  the  tibia  and  foot,  and  the  great-toe  (i.e.,  the  distribution  of  the 
internal  saphenous  nerve).  The  anaesthesia  was  less  perfect  in  the 
legs  than  in  the  buttocks.  On  going  to  stool,  the  patient  could  not 
pass  a  motion  until  he  had  pressed  upon  the  perineum,  but  very 
light  pressure — even  merely  wiping  the  anus — was  sufficient,  so 
that  the  action  was  probably  not  entirely  mechanical.  Pain  in 
the  lower  limbs  was  very  severe,  especially  on  movement,  and  he 
had  often  much  pain  about  the  anus ;  those  symptoms  being  so 
severe  as  to  necessitate  hypodermic  injections  of  morphia. 

A  month  later  he  could  still  move  the  lower  limbs  in  all  direc- 
tions, but  only  with  the  greatest  difficulty,  and  apparently  some- 
what better  on  the  right  than  on  the  left  side ;  there  was  also 
extreme  wasting  of  the  limbs,  but  it  was  difficult  to  say  that  one 
group  of  muscles  was  more  affected  than  another.  The  plantar 
and  cremasteric  reflexes  were  exaggerated,  the  gluteal  absent  on 
both  sides.      The  knee-jerk  was,  as  before,  well  marked,  but  there 


92 


SURGERY    OF   THE   SPINAL   CORD. 


*vvas  no  ankle-clonus.     With  the  faradic  current  the  gastrocnemius 


Fio.  13 


h'lG.  14. 


and  glutei  gave  no  reaction ;    the  anterior  leg-muscles  and  all 


INJURIES    TO   THE    CAUDA   EQUINA.  93 

those  of  the  thigh  reacted  to  a  current  of  medium  strength.  The 
following  table  shows  the  number  of  cells  required  to  produce 
contraction  with  the  constant  current: — 


Kathodiil  Closure. 

Anodal  Closure. 

Cells. 

Cells. 

Biceps  fenioris  (right) 

30 

30 

„        (left)    . 

35 

30 

Gluteus  maximus  (right) 

20 

20 

(left) 

15 

25 

Extensors  of  foot  (right) 

40 

40 

„        (left) 

40 

40 

Extensors  of  knee  (left) 

30 

45 

Gastrocnemius  (right) 

30 

35 

(left)    . 

45 

45 

Fig.  17. 


The  distribution  of  the  anajsthesia  at  this  date  is  indicated  by 
the  accompanying  diagrams  (figs.  13-17).  Pain  was  still  very 
great,  but  the  general  health  re- 
mained fairly  good.  There  was 
some  redness  over  the  trochanters 
and  sacrum. 

From  this  time  the  patient  lost 
ground  rapidly.  Tlie  skin  became 
sore  at  several  points,  an  abscess 
formed  over  the  right  trochanter 
major,  the  pain  was  intense,  the 
appetite  failed,  and  the  temperature 
became  hectic,  varying  from  97°  in 
the  morning  to  103.6°  in  the  even- 
ing. On  September  1 1  he  was  or- 
dered drachm  doses  of  liq.  hyd.  perchlor.  with  grs.  ij.  of  pot.  iod. 
three  times  a  day,  but  no  improvement  followed.  Morphia  had 
to  be  used  constantly. 

On  November  i  a  bed-sore  formed  over  the  sacrum,  and  on 
November  i  5  he  had  convulsions  and  died  in  the  afternoon. 

No  notes  were  taken  of  the  post-mortem  examination,  but  Dr. 
Ross,  who  was  present,  and  Professor  Young,  who  was  at  that 
time  pathologist  to  the  Infirmary,  remember  that  there  was  found 
only  a  very  small  tumour — a  fibro-sarcoma  about  the  size  of  a 
hemp-seed — situated  on  one  of  the  nerve  cords  of  the  cauda,  with 
no  signs  of  diftused  infiltration  or  inflammation.  It  is,  however, 
obvious  that  there  must  have  been  some  lesion  of  more  than  the 
one  nerve  root,  and  no  microscopic  examination  was  made  of  the 
others.      The  spinal  cord  itself  was  perfectly  normal. 


94  SURGERY    OF  THE    SPINAL   CORD. 

We  have  liere  the  same  distribution  of  anaesthesia  as  in  Cases 
29  and  30,  but  the  notes  contain  no  reference  to  the  relative 
power  of  the  thigh-muscles.  The  reaction  of  degeneration  was 
again  absent.  Owing  to  the  nature  of  the  lesion,  the  anaesthesia 
was  preceded  by  intense  pain,  and  the  symptoms  were  at  first 
more  marked  on  the  left  than  on  the  right  side.  The  retention 
of  the  knee-jerk  and  plantar  reflexes  is  unusual,  but  some 
exaggeration  of  reflex  action  is  by  no  means  rare  in  the  earlier 
stages  of  peripheral  nerve-lesions,  before  irritation  has  given  rise 
to  complete  annihilation  of  function.  The  nature  of  the  lesion 
was  here  placed  beyond  any  possible  doubt  by  the  post-mortem 
examination,  which  showed  that  the  cauda  equina,  and  not  the 
spinal  cord  itself,  was  the  region  involved. 

A  closely  similar  case  is  mentioned  and  figured  by  Dr.  Gowers,^ 
who  notes  that  tactile  sensibility  was  impaired  "  chiefly  in  the 
region  supplied  from  the  sacral  plexus,"  and  that  although  the 
lower  limbs  were  paralysed,  "  a  little  power  in  the  flexors  of  the 
hips  and  extensors  of  the  knees  persisted  almost  to  the  last." 
Hence,  in  Dr.  Gowers'  case  also  the  anterior  crural  nerve  was  less 
profoundly  affected  than  the  branches  below  it.  His  figure 
shows  a  tumour  of  the  cauda  equina  immediately  below  the 
termination  of  the  cord. 


Case  32. — Dislocation  forwards  of  the  second  lumbar  vertebra — 
Compression  of  the  cauda  equina. 

R.  M.  C,  aged  fifteen,  male,  a  collier  by  occupation,  was 
admitted  to  the  Infirmary  under  Mr.  Jones's  care  on  December 
31,  1886. 

About  the  end  of  the  previous  August,  while  he  was  in  the 
pit,  and  probably  in  a  stooping  posture,  a  stone  weighing  five  or 
six  cwts.  fell  from  the  roof — a  distance  of  about  five  feet — on  to 
his  shoulders,  bending  him  forwards  with  his  head  between  his 
knees  and  his  right  leg  under  him.  On  being  extracted,  he  was 
found  to  have  a  fracture  of  the  right  femur,  and  this  was  ap- 
parently the  only  injury  diagnosed  at  that  time  ;  but  he  had  much 
pain  in  the  lower  part  of  the  back  and  in  both  hips,  and  was 
unable  to  sit  up  in  bed.  Some  nine  weeks  later,  he  could  sit  in 
a  chair.  He  was  never  able  to  move  his  feet  after  the  accident, 
and  not  for  a  fortnight  had  he  any  power  over  either  thigh.  He 
had  never  any  pain  or  other  unusual  sensations  in  the  fractured 

^  Diseases  of  the  Nervous  System,  vol.  i.  p.  420. 


INJURIES    TO    THE   CAUDA    EQUINA.  95 

limb,  from  which  we  may  assume  that  it  was  anaesthetic.  For 
six  weeks  after  the  accident  his  urine  had  to  be  drawn  off 
systematically  with  a  catheter,  and  from  about  the  third  week 
he  had  symptoms  of  cystitis,  which  still  continued  on  admission. 
Since  the  sixth  week  no  catheter  has  been  used,  and  he  has  been 
able  to  pass  water,  nor  has  he  ever  had  any  incontinence  ;  but 
micturition  is  very  slowly  performed.  Constipation  has  been 
present  throughout,  but  there  has  never  been  any  involuntary 
defecation. 

On  admission,  we  found  a  prominence  of  one  of  the  lumbar 
spinous  process  (the  third)  one  inch  above  the  level  of  the  pos- 
terior superior  iliac  spines.  Above  and  below  this  were  depres- 
sions, and  to  the  left  of,  and  a  little  above  it,  another  bony 
prominence,  due  apparently  to  the  displaced  transverse  process 
of  the  second  lumbar  vertebra.  There  was  slight  pain  and  ten- 
derness in  this  region. 

The  lower  limbs  presented  partial  paralysis,  but  could  be  moved 
about  the  bed  to  some  extent.  The  hips  could  be  moved  in 
every  direction,  but  adduction  was  more  powerful  than  any  other 
movement ;  extension  and  flexion  were  about  equally  vigorous, 
and  abduction  very  weak ;  at  the  knee  extension  was  more 
powerful  than  flexion.  In  the  ankle  and  foot  no  movements 
could  be  produced.  The  muscles  of  the  buttocks  and  lower 
limbs  were  wasted,  those  below  the  knees  being  especially  so  ; 
none  of  the  lower  limb  muscles  contracted  with  a  faradic  current 
of  such  strength  as  the  patient  could  bear,  but  we  were  unable 
to  test  the  galvanic  reactions  satisfactorily.  The  knee-jerk  was 
absent,  as  was  the  plantar  reflex,  the  cremasteric  and  gluteal 
being  well  marked  and  apparently  exaggerated. 

There  was  nowhere  absolute  anaesthesia,  but  sensation  was 
obtuse  over  the  lower  part  of  the  gluteal  region,  and  thence  down 
the  back  of  the  thighs  and  legs  to  the  soles  of  the  feet,  as  well 
as  over  the  front  of  the  legs  and  the  dorsum  of  the  feet.  It 
was  much  less  imperfect  on  the  front  of  the  thighs  than  elsewhere 
in  the  lower  limbs,  and  was  better  on  the  inner  than  on  the 
outer  side  of  the  legs.  Over  the  genitals  also  sensation  was 
much  blunted,  but  not  absent,  and  a  catheter  was  felt  along  the 
whole  of  the  urethra.  The  passage  of  faeces  was  also  felt.  He 
stated  that  sensation  had  gradually  improved  since  the  accident. 
The  feet  always  felt  cold  to  the  patient,  but  there  was  no  pain 
or  hyperaesthesia. 

The  skin  of  the  lower  limbs  presented  no  abnormalities.  Pria- 
pism was  common ;  the  urine  was  alkaline,  containing  some  pus 


96  SURGERY    OF    THE   SPINAL    CORD. 

and  phosphates,  and  there  was  pain  over  the  pubes,  and  smarting 
on  micturition. 

On  January  15th — a  fortnight  after  admission — Mr.  Jones 
proceeded  to  trephine  the  spine  in  the  affected  region.  Chloro- 
form having  been  administered,  the  patient  was  turned  on  to  his 
face,  and  an  incision  four  inches  in  length  was  made  in  the  middle 
line,  with  its  centre  over  the  prominent  spinous  process.  From 
either  end  of  this  an  incision  of  some  three  inches  in  length  was 
carried  at  right  angles  to  it,  and  to  the  left.  The  superficial 
structures  were  thus  dissected  up  in  a  flap,  and  the  muscles  were 
then  separated  by  blunt  dissection,  drawn  aside  from  the  vertebral 
groove,  and  held  back  by  retractors.  It  was  now  clear  that  the 
arch  of  the  second  lumbar  vertebra  was  displaced  forwards,  the 
prominent  spine  being  that  of  the  third,  so  that  the  displacement 
was  that  most  commonly  met  with — dislocation  forwards  of  the 
upper  part  of  the  spine.  At  the  same  time  the  spine  of  the  second 
lumbar  vertebra  was  broken  off  and  isolated,  and  the  prominence 
above  mentioned  as  lying  to  the  left  of  the  middle  line  proved  to 
be  the  articular  process  of  the  third  lumbar,  its  articular  surface 
being  exposed  by  the  dislocation  forwards  of  that  of  the  second. 
The  detached  spine  of  the  second  vertebra  was  removed,  and 
showed  a  gap  between  the  arches  of  the  second  and  third,  filled 
with  dense  cicatricial  tissue.  By  means  of  bone  forceps,  the  arch 
of  the  second  lumbar  was  now  almost  entirely  removed,  exposing 
the  membranes  of  the  cord,  which  had  obviously  been  compressed 
by  it.  Around  these  membranes  there  was  also  cicatricial  tissue, 
which  was  not  interfered  with.  The  flap  was  replaced  and  sutured, 
a  drainage  tube  being  placed  at  its  lower  angle,  and  the  wound 
dressed  with  wood-wool. 

No  trouble  followed  the  operation,  and  the  wound  healed  well, 
but  rather  slowly,  the  temperature  being  more  or  less  raised  for 
about  a  fortnight  afterwards.  Five  days  later  the  patient  stated 
that  the  sensation  of  coldness  in  the  feet  had  disappeared.  After 
a  week  the  faradic  current  was  used  to  the  muscles,  and  caused 
slight  contractions  in  the  posterior  thigh-muscles,  a  more  marked 
effect  in  the  anterior  muscles  and  adductors,  but  none  in  the  legs. 
The  galvanic  current  was  never  used,  as  the  patient  would  not 
submit  to  it,  and  struggled  when  it  was  tried.  Sensation  improved 
somewhat,  and  the  thigh-muscles  became  much  stronger  during  the 
ensuing  two  months,  but  no  power  of  motion  returned  in  the  leg- 
muscles.  In  this  condition  he  was  sent  to  the  Convalescent 
Hospital  at  Cheadle  on  April  2,  two  months  and  a  half  after  the 
operation. 


INJURIES    TO    THE   CAUDA   EQUINA.  9? 

A  month  later,  when  I  saw  him  at  Cheadle,  he  could  stand 
up,  and  could,  by  means  of  chairs,  &c.,  walk  a  little ;  the  thigh- 
muscles  were  fairly  developed,  and  the  hip  and  knee  joints  freely 
movable,  but  the  leg-muscles  remained  atrophied,  and  he  could 
not  move  the  ankles  or  toes.  The  thigh-muscles  reacted  to  the 
faradic  current,  but  those  of  the  legs  did  not ;  it  was  not  possible 
to  obtain  accurate  galvanic  observations,  but  apparently  the  ascend- 
ing and  descending  currents  were  equally  effective  in  producing 
contractions  of  the  thigh-muscles,  and  equally  unable  to  affect 
those  below  the  knees.  Occasionally  he  had  muscular  tremors. 
Sensation  appeared  to  be  everywhere  normal,  but  was  perhaps  a 
little  less  acute  on  the  outer  than  on  the  inner  side  of  each  leg. 
The  superficial  reflexes  were  well  marked,  the  knee-jerk  absent, 
A  small  quantity  of  pus  still  remained  in  the  urine,  but  this  slight 
cystitis  caused  no  subjective  symptoms.  A  fortnight  afterwards, 
when  I  saw  him  again,  he  could  walk  with  the  aid  of  one  stick 
only,  but  with  marked  dragging  of  the  toes.  There  was  no  other 
change. 

About  eighteen  months  after  the  last  date  this  lad  was  shown 
by  Mr.  Jones  to  the  members  of  the  Manchester  Medical  Society. 
He  was  then  at  work  as  a  collier,  and  could,  with  the  aid  of  a 
stick,  walk  several  miles,  but  the  muscles  of  the  feet  and  flexors 
and  extensors  of  the  toes  remained  paralysed,  and  there  was  some 
contraction  of  the  posterior  thigh-muscles,  causing  the  knees  to 
be  always  slightly  bent. 

The  relationship  of  this  case  to  the  three  first  cited  is  obvious, 
and  the  localisation  of  the  lesion  indubitable.  The  most  interest- 
ing point  in  the  symptoms  is  the  slight  interference  with  sensation 
as  compared  with  motion. 

We  are  now  in  a  position  to  compare  the  above  four  cases, 
which,  although  differing  somewhat  in  their  details,  resemble  one 
another  sufficiently  in  their  broad  outlines  to  form  a  distinctly 
marked  group.  For  this  purpose  I  have  arranged  the  leading 
symptoms  in  the  form  of  a  Table,  showing  the  similarities  and 
points  of  difference  in  each  case. 


Q 


98 


SURGERY   OF   THE   SPINAL   CORD. 


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INJURIES   TO   THE   CAUDA   EQUINA.  99 

It  is  to  be  remembered  that  the  spinal  cord  terminates  at  the 
level  of  the  lower  border  of  the  first  lumbar  vertebra,  whence  the 
nerves  of  the  lumbar  and  sacral  plexuses  descend  in  order  to  pass 
out  from  the  spinal  canal,  each  immediately  beneath  the  vertebra 
from  which  it  takes  its  name.  Hence,  in  all  of  these  cases  the 
lesion  was  so  situated  as  to  compress  the  entire  cauda  equina, 
and  the  cauda  equina  only ;  and  further,  in  Case  29,  the  whole 
of  the  lumbar  and  sacral  nerves  pass  out  beneath  its  level, 
whereas  in  Case  32  it  involves  all  but  the  ilio-inguinal  and  ilio- 
hypogastric ;  in  Cases  30  and  3  i  the  exact  level  of  the  pressure 
cannot  be  ascertained,  but  must  clearly  have  been  almost  the 
same  as  in  Cases  29  and  32. 

In  all  of  these  the  salient  point  is  that,  although  the  whole,  or 
almost  the  whole,  of  the  nerves  of  the  cauda  pass  the  level  of  the 
lesion,  those  which  escape  from  the  spinal  canal  lower  down  are 
more  seriously  injured  by  the  pressure.  Why  this  should  be  so 
is  not  clear.  Those  nerves  which  pass  out  lower  down  are,  in 
the  cauda,  situated  nearer  the  middle  line  than  those  which  pass 
out  above  them,  and  hence  they  would  appear  to  have  more  room 
to  escape  from  pressure,  and  we  might  expect  them  to  suffer  less 
rather  than  more ;  but  that  the  contrary  is  the  case  is  an  esta- 
blished fact,  and  we  are  able  definitely  to  conclude  that,  in  a 
pressure-lesion  of  the  entire  cauda  equina,  those  nerve-roots  which 
emerge  lower  down  are  more  seriously  injured  than  those  above 
them,  a  conclusion  the  importance  of  which  will  be  more  obvious 
in  the  following  chapter. 

As  already  stated,  the  above-described  combination  of  symp- 
toms has  been  several  times  noted  by  former  writers,  but,  as  in 
other  cases  of  spinal  injuries,  the  descriptions  given  are  usually 
so  meagre  as  to  render  the  diagnosis  anything  but  clear.  The 
annexed  Table  (pp.  100—105)  gives  a  few  instances,  from  several 
hundreds  of  cases  of  spinal  injury,  of  which  I  have  abstracted 
the  records,  showing  more  or  less  clearly  the  same  group  of 
symptoms,  and  indicating  the  various  interpretations  that  have 
been  placed  upon  them.  The  Table  does  not  pretend  to  be 
exhaustive,  but  merely  illustrative  : — 


lOO 


SURGERY   OF   THE   SPINAL   CORD. 


Case 

Reference. 

Sex. 

Age. 

Result. 

Probable 
Lesion. 

Paralysis,  &c. 

Reflexes. 

A. 

Erichsen, 
Concus- 
sion of  the 
Spine,  2nd 
ed.  p.  30. 

M. 

14 

Recovery 
in  f  our 
months. 

Inflamma- 
tion around 

Cauda 

equina,  more 

marked  on 

left  side. 

Came  on  gradually  dur- 
ing ten  days.     Could 
then   not   stand,   but 
moved  legs  in  bed  ;  no 
complete  paralysis  ex- 
cept in  peronei  and  ex- 
tensors of  left  ankle. 
Rapid  wasting  of  left 
leg. 

Paralysis  below  the  seat 

No  note. 

B. 

Lidell, 

M. 

19 

Unknown. 

Gunshot 

No  note. 

Ashurst's 

wound  in 

of  injury. 

System  of 

lumbar 

Surgery, 

region. 

vol.  vi. 

p.  789. 

C. 

OUivier, 

Traits  des 

Maladies  de 

la  Moelle 

Epiniere, 

vol.  i.  p.  358. 

M. 

40 

Partial 
recovery. 

Gunshot 

wound  in 

lumbar 

region. 

None. 

No  note. 

D. 

Ollivier, 
ibid.  p.  515- 

M. 

22 

Partial 
Recovery. 

Crush  of 
Cauda 
equina. 

At  first  complete  para- 
plegia. After  two  years 
could  walk  with  assist- 
ance ;  ankle-joint  flail- 
like ;  could  flex  but  not 
extend  the  thigh,  and 
extend  but  not  flex  the 
leg. 

Lower  limbs  were  para- 

No note. 

E. 

Hutchinson, 

M. 

42 

Death  in 

Dislocation 

No  note. 

Lond. 

five 

of  2nd 

lysed  with  the  excep- 

Hosp. Rep., 

weeks. 

lumbar 

tion   of   the   anterior 

vol.  iii 

vertebra. 

thigh-muscles. 

iP-  343. 

F. 

Hutchinson, 

Lond. 

Hosp.  Rep., 

voL  iii. 

p.  326- 

M. 

9 

; 

Recovery 
in  four 
months. 

Fracture 
in  upper 
lumbar) 
region. 

Paralysis  of  the  legs.  On 
eighth  day  could  draw 
up  both  legs,  the  right 
with  greater  difficulty 
than  the  left. 

No  note. 

INJURIES   TO   THE   CAUDA   EQUINA. 


lOI 


Ansesthesia. 

Bladder  and 
Rectum. 

Vaso-motor 
and  Trophic. 

Local 
Symptoms. 

Post- 
mortem. 

Remarks. 

Numbness  and  ting- 

Occasional 

Coldness  of 

Tender- 

There were 

ling  on  outer  side 

loss  of 

extremities, 

ness  over 

also  symp- 

of left  thigh  ;  par- 

control 

especially 

third 

toms  of 

tial  loss  of  sensa- 

over 

of  left 

lumbar 

cervical 

tion    below    left 

sphincters. 

foot. 

vertebra 

injury. 

knee.    Right  limb 

after  loth 

normal. 

day. 

Diminished     sensa- 

Retention 

No  note. 

Gunshot 

Author  re- 

tion below  seat  of 

of  urine. 

wound. 

gards  as  a 

injury.        Hyper- 

case  of  con- 

sesthesia of  front 

cussion, 

and  inner  side  of 

because  the 

thigh.  Anaesthesia 

retention  of 

of  urethra  anterior 

some  sensa- 

to pars  prostatica. 

tion  shows 
that  there 

was  no 

serious  cord 

lesion. 

Absolute  anaesthesia 

Inconti- 

None. 

Gunshot 

Case  seen 

of     postero-inter- 

nence  of 

wound. 

nine  years 

nal  and    anterior 

urine. 

after  injury. 

parts  of  thighs ;  of 

penis  and  scrotum. 

After  two  years  anaes- 

Involuntary 

No  note. 

Contusion 

Reported 

thesia  of  feet,  back 

urination 

in  lumbar 

as  a  case  of 

of      legs,     thighs, 

and  defae- 

region. 

concussion. 

buttocks,  scrotum, 

cation. 

and  penis.   Perfect 

sensation  in   front 

of  limbs  from  groin 

to  ankle. 

Complete  anaesthesia 

At  first 

Bed-sore. 

Absent. 

Fracture  of 

of    soles ;    partial 

retention. 

body  and 

loss  of  sensation  of 

later 

dislocation 

rest  of  limbs,   ex- 

dribbling 

forwards  of 

cept       front       of 

of  urine. 

second 

thighs.    Sensation 

Retention 

lumbar  ver- 

better    on     inner 

of  faeces. 

tebra,  the 

than  on  outer  side 

Cauda  equina 

of  thighs.     Some- 

being 

times  felt  passage 

' '  lifted  on 

of  catheter. 

a  bridge  of 

displaced 

bone. " 

Anaesthesia  of  geni- 

Retention 

No  pria- 

Promi- 

From the 

tals,  but  condition 

of  urine. 

pism. 

nence  of 

distribution 

of  limbs  not  at  first 

Involuntary 

the  spine 

of  the  anaes- 

noted.    Felt   pain 

defaecation. 

"in  the 

thesia,  and 

when  catheter  en- 

Urine am- 

lumbar 

from  the  po- 

tered bladder.    On 

moniacal 

region. " 

sition  of  the 

8th  day  had  perfect 

for  a  time. 

spinal  pro- 

sensation in  front 

On  39th  day 

minence, 

of  thighs.  On  39th 

had  desire, 

the  author 

day  had  sensation 

but  no 

thought 

in  front  of  thighs 

power  to 

it  probable 

and  legs,  in  hypo- 

pass water. 

that  the 

gastric  region  and 

lesion  affec- 

scrotum; good  sen- 

ted the 

sation  in  first  and 

fourth  or 

second  toes,    par- 

fifth lumbar 

tial  in  the  others. 

vertebra. 

Complete       anaes- 

thesia of  back  and 

inner  sidesof  thighs. 

I02 


SURGERY    OF    THE   SPINAL    CORD. 


Case 


G. 


Hutchinson, 

Lond. 
Hosp.  Rep., 

vol.  iii. 

P-  332. 


H. 


Sex. 


M. 


Age. 


33 


Result. 


Probable 
Lesion. 


Partial 
recovery 
in  three 
months. 


M'Donnell, 

Dublin 

Quart.  Jour. 

Med.  Sci., 

1866. 

vol.  xlii. 


K. 


Leyden, 

Klinik  der 

Eiicken- 

marks- 

krankhei- 

ten,  vol.  ii. 

p.  143- 


M. 


M. 


31 


45 


Dislocation 

of  second 

lumbar 

vertebra. 


Partial 
recovery 
in  twelve 
months. 


Death  in 
seven 
weeks. 


Fracture 
in  upper 
lumbar 
region. 


Fracture- 
dislocation 
of  first 
lumbar 
vertebra. 


Paralysis,  &c. 


Paralysis  of  lower  limbs 
foUowedby  some  wast- 
ing, especially  of 
glutei. 


At  first,  paralysis  of 
lower  limbs.  At  end 
of  second  month,  com- 
plete paralysis  below 
the  knees,  and  very 
little  power  in  the 
thigh-muscles  except 
the  sartorius. 


Reflexes. 


No  note. 


No  re- 
flexes 
below 
knees. 
Exagge- 
rated in 
thighs 


Lower  limbs  were  para- 
lysed, but  some  power 
remained  in  adductors 
and  anterior  muscles 
of  left  thigh.  After 
three  weeks  there 
were  cramps. 


Not  in- 
creased" 


INJURIES   TO   THE   CAUDA   EQUINA. 


TO' 


Aiisesthesia. 

Bladder  and 
Rectum. 

Vaso-motor 
and  Trophic. 

Local 
Symptoms. 

Post- 
mortem. 

Remarks. 

Anaesthesia  of  scro- 

Retention 

Projection 

tum,    penis,    and 

of  urine 

of  third 

urethra;  partially 

and  faeces. 

lumbar 

of    thighs ;     com- 

vertebra. 

pletely  of  legs.   At 

interval   of   three 

months,    anaesthe- 

sia of    feet,    but- 

tocks,   and    peri- 

neum ;    numbness 

of  penis,  scrotum. 

and  urethra ;  fairly 

good  sensation  in 

thighs ;  better  sen- 

sation    on     soles 

i 

than  on  dorsum  of 

feet,  and  on  inner 

than  on  outer  side 

of  leg. 

At  first  anaesthesia 

Retention 

Occasional 

An  im- 

The spine 

of  lower  limbs.  At 

of  urine, 

priapism. 

movable 

was  tre- 

end of  two  months 

followed  in 

"Wasting  of 

projection 

phined, 

had  anaesthesia  of 

four  or  five 

lower  limbs. 

four  inches 

which  was 

feet,  obscure  sen- 

days by 

Perspiration 

above  level 

followed  by 

sation  from  ankle 

inconti- 

of feet  and 

of  um- 

some im- 

to knee,  especially 

nence.   Am- 

ankles. 

bilicus. 

provement 

on       left      side ; 

moniacal 

CEdema  of 

in  the 

hypersesthesia     of 

urine. 

penis  and 

symptoms. 

thigh,     especially 

scrotum. 

on  right  side. 

Urethritis, 

cystitis. 

Bed-sore  on 

back. 

Anaesthesia  of  lower 

Retention 

No  erections. 

No  note. 

Fracture  of 

See  text. 

limbs,  except  from 

of  urine 

Sweating 

first  lumbar 

This  is 

front  of  left  thigh 

and  faeces. 

of  feet ; 

vertebra,  the 

given  by 

to  dorsum  of  foot, 

oedema  of 

cartilage 

the  author 

the  loss  of  sensa- 

lower 

immediately 

as  a  typical 

tion  extendins;  as 

limbs  and 

below  which 

case  of 

high  as  the  but- 

scrotum. 

projected 

traumatic 

tocks  and  sacrum. 

Bed-sores  of 

backwards 

myelitis. 

affecting  also  the 

feet  and 

some  J  inch 

penis  and  urethra ; 
but    less    marked 

sacrum. 

(7  mm.). 

Lumbar  cord 

on  the  front  than 

swollen,  soft 

on  the  back  of  the 

and  pale. 

thighs.         Hyper- 

Other  secon- 

aesthesia    in     in- 

dary lesions. 

guinal          region. 

shooting  pains   in 

limbs  and  pain  in 

bladder. 

104 


SURGERY    OF   THE   SPINAL   CORD. 


Reference. 


Leyden, 

Klinik  der 

Kiicken- 

marks- 

krankhei- 

ten,  ToL  i. 

p.  340. 


Sex. 


Hamilton, 

Dublin 

Quart.  Jour. 

Med.  Sci., 

^vol,  vi. 


Hatton, 

Dublin 

Jour. 

Med.  Sci., 

vol.  zxL 

1842. 


M. 


M. 


Age. 


32 


25 


M. 


Result. 


Death  in 

five 
months. 


Death  in 

two 
months. 


Probable 
Lesion. 


Fracture 

of  twelfth 

dorsal  and 

first  lumbar 

laminae. 


Fracture 
through 
body  and 
laminae  of 
second 
lumbar 
vertebra. 


Death  in       Fracture 
six  weeks.       of  first 
lumbar 
vertebra. 


Paralysis,  &c. 


Reflexes. 


Lower  limbs  almost  com-  No  note, 
pletely  paralysed,  but 
had  some  power  of  ro- 
tating and  adducting 
thighs,  and  attempts 
at  flexion  of  knees. 
Complete  passive 
flexion  of  knees  pre- 
vented by  spasm  of 
quadriceps.  Adduc- 
tion and  inwards  rota- 
tion of  left  thigh. 
Occasional  cramps  and 
tremors.  Muscles  of 
legs  and  back  of  thighs 
did  not  react  to  farad. 
cuiTent,  but  those  of 
front  of  thighs  did  so 
readily. 


Paralysis  of  lower  limbs.  No  note 


Loss  of  power  of  the 
lower  extremities. 


No  note 


I  shall  not  add  anything  with  regard  to  the  details  of  the 
symptoms  in  the  above,  which  are  suflBciently  similar  to  my  own 
cases,  but  merely  wish  to  adduce  evidence  in  favour  of  their 
being  due  to  pressure  upon  the  cauda  equina.  Case  A.  is  attri- 
buted by  the  author  to  "  intraspinal  haemorrhage,"  but  the  date 
of  appearance  and  the  seat  of  tenderness  would  seem  to  warrant 
the  interpretation  given  in  the  Table.  Case  B.  appears  to  me 
to  be  most  typical,  and  I  entirely  fail  to  appreciate  the  reason 


INJURIES    TO    THE   CAUDA   EQUINA. 


105 


Anaesthesia. 

Bladder  and 
Rectum. 

Vasa-motor 
and  Trophic. 

Local              Post- 
Symptoms,       mortem. 

Remarks. 

1 

Anaesthesia  not  com- 

Retention 

Slight 

Spinous 

Fracture  of 

Death  from 

plete,    but    sensa- 

of urine 

cfidema 

process  of 

twelfth  dor- 

uraemia. 

tion  almost  lost  in 

and  faeces. 

of  legs. 

first  lum- 

sal and  first 

the      feet,      very 

Bedsore  on 

bar  verte- 

lumbar lami- 

obscure   in    legs. 

sacrum. 

bra  pro- 

nae, and  of 

back    of     thighs, 

jected 

body  of  first 

and  buttocks ;  bet- 

backwards lumbarverte- 

ter    in     front    of 

and  to  the'  bra  ;  tear  of 

thighs. 

right. 

dura  mater ; 
compression 
of  cord  and 
caudaequina. 
Inflamma- 
tion of  pia 
mater  and 
softening  of 
cord  extend- 
ing to  U]iper 
level  of  lum- 
bar region. 
Secondary 
lesions. 

At  first    there   was 

Retention 

Projection 

Fracture 

Death  from 

anaesthesia,  except 

of  urine. 

of  second 

through 

erysipelas. 

on  the  front  of  the 

followed  by 

lumbar 

upper  part 

thighs.     In  a  few 

symptoms 

spine. 

of  body  of 

days    this    region 

of  cystitis. 

second 

was  also  affected. 

lumbar 

but       again      re- 

vertebra and 

covered. 

its  laminae, 
with  com- 
pression of 

the  cord 

"  just  above 

the  Cauda 

equina." 

The  "  external  parts 

Retention 

Bedsore  on 

Interval 

An  oblique 

of  the  lower  limbs 

of  urine 

left  buttock. 

between 

fracture  of 

were  quite  insen- 

and faeces. 

The  right 

last  dorsal 

the  body  of 

sible,  the  internal 

Cystitis. 

tibia  and 

and  first 

the  first 

still    retaining    a 

fibula  were 

lumbar 

lumbar  ver- 

considerable share 

also  broken 

vertebrae. 

tebra,  with 

of  sensibility." 

and  united 
readily. 
Temp,  of 

lower  limbs 
was  "at 

first "  62°, 

afterwards 

compression 
of  the  cord 
and  Cauda 

equina, 

which  were 

bathed  in 

pus. 

95°- 

given  for  regarding  it  as  an  instance  of  "  concussion."  The  lesion 
was  below  the  region  of  the  cord  itself  and  over  that  of  the  cauda 
equina,  and  the  symptoms  are  those  of  pressure  upon,  or  partial 
destruction  of,  the  latter.  In  Case  F.  Mr.  Hutchinson  places  the 
probable  seat  of  the  lesion  at  the  fourth  or  fifth  lumbar  vertebra, 
a  conclusion  which,  in  view  of  our  cases,  is  hardly  warranted  by 
the  nature  of  the  nervous  symptoms  described.  At  first  all  the 
muscles  of  the  lower  limbs  seem  to  have  been  paralysed  (unfor- 


I06  SURGERY    OF    THE    SPINAL   CORD. 

tunately,  sensation  was  not  at  tliat  time  accurately  noted),  thus, 
it  would  seem,  indicating  that  the  entire  cauda  equina  was 
primarily  paralysed,  but  that  recovery  of  the  higher  roots  rapidly 
ensued. 

The  best  description  is  that  of  Ley  den  (Case  K.),  who  appears 
to  have  attributed  the  symptoms  mainly  to  myelitis,  and  not  to 
the  crush  of  the  cauda  equina;  but  although  the  co-existence  of 
myelitis  is  proved  by  the  post-mortem  appearances,  the  site  of  the 
lesion  and  the  fact  that  the  symptoms  followed  immediately  after 
the  accident,  appear  to  indicate  a  primary  lesion  of  the  cauda 
equina.  In  the  other  cases,  the  localisation  is,  as  a  rule,  obvious 
enough  from  the  facts  above  furnished. 

In  conclusion,  I  would  draw  attention  to  certain  points  in  the 
diagnosis  of  these  cases  of  pressure  upon  the  cauda  equina. 

1.  From  locomotor  ataxia.  In  a  traumatic  case  there  is  little 
likelihood  of  confusion,  although  even  here  the  affection  might 
possibly  be  regarded  as  ataxia  consequent  upon  an  injuiy.  But 
in  a  case  of  tumour  or  spina  bifida,  &c.,  the  occurrence  of  a 
perforating  ulcer,  pains  in  the  limbs,  patches  of  anaesthesia,  loss 
of  knee-jerk,  and  some  difficulty  in  walking,  with  or  without 
bladder  troubles,  might  well  mislead  the  unwary.  We  must 
then  note  the  absence  of  pupil  symptoms,  of  girdle-pains,  gastric 
crises,  &c. ;  on  the  other  hand,  we  shall  find  the  peculiar  distri- 
bution of  the  anaesthesia  as  above  described  ;  the  afiected  muscles 
will  be  more  wasted  than  in  ataxia,  and  may  present  the  reaction 
of  degeneration,  and  there  will  be  loss  of  power  as  well  as  inco- 
ordination. The  gait  differs  from  that  of  ataxia,  and  is  charac- 
teristic, there  being  not  only  clumsiness  and  sprawling,  but 
marked  dropping  of  the  toes. 

2.  From  injury  or  disease  of  the  lower  part  of  the  spinal 
cord.  Here  we  must  be  guided  by  the  exact  site  of  the  local 
symptoms,  if  any  be  present,  remembering  that  the  cord  does 
not  extend  below  the  lower  border  of  the  first  lumbar  vertebra. 
Failing  this,  the  diagnosis  becomes  one  of  very  great  difficulty, 
the  only  other  differential  symptom  being  the  existence  of  con- 
stant pain  or  hyperaesthesia  above  the  anaesthetic  region,  a  condi- 
tion which  points  rather  to  the  cauda  equina  than  to  the  cord 
itself  as  the  seat  of  disease.  In  lesions  of  gradual  increase,  such 
as  tumours,  the  rate  of  production  of  the  various  symptoms  will 
assist  us,  as  in  Case  48,  where  a  history  of  six  years'  progressive 
development  points  rather  to  an  affection  of  the  cauda  than  of  the 
spinal  cord.  Asymmetry  of  the  symptoms  also  probably  indi- 
cates a  lesion  of  the  cauda  equina. 


INJURIES   TO    THE   CAUDA   EQUINA.  I07 

3.  From  extra-spinal  diseases  and  injuries  of  the  nerves  to  the 
lower  limbs.  We  have  here  several  difficulties  to  contend  with, 
but  in  most  instances  a  careful  consideration  of  the  case  will  lead 
to  a  correct  conclusion.  The  only  peripheral  disease  liable  to  be 
mistaken  for  an  affection  of  the  cauda  equina  is  some  variety  of 
multiple  peripheral  neuritis,  and  here  we  may  usually  decide  the 
point  by  finding  some  affection  of  the  upper  limbs,  by  the  marked 
preference  of  that  disease  for  the  extensor  surfaces,  and  by  the 
slighter  sensory  symptoms.  In  cases  of  injury  the  difficulty  is 
greater.  Even  the  limitation  of  symptoms  to  one  side  of  the  body 
is  not  an  absolutely  pathognomonic  sign,  as  is  indicated  by  Mr. 
Erichsen's  case  (Case  A.,  Table).  Nevertheless,  complete  unilateral 
distribution  or  perfect  symmetry  would  be  strong  arguments  for 
the  lesion  being  respectively  outside  or  inside  the  spinal  canal. 
We  are  again  aided  by  the  site  of  any  local  signs  of  injury ;  and 
finally,  we  might  with  certainty  pronounce  the  case  to  be  an 
affection  of  the  cauda  if  we  found  the  distribution  of  the  sensory 
and  motor  symptoms  to  accord  closely  with  the  above-described 
types. 


CHAPTER  V. 

INJURIES  OF  THE  LUMBO-SACRAL  REGION  OP 
THE  SPINAL  CORD. 

As  in  the  case  of  the  cervical  region  of  the  spinal  cord,  we 
may,  before  entering  upon  a  study  of  traumatic  lesions  of  the 
lumbo-sacral  region,  recapitulate  briefly  the  conclusions  of  previous 
observers  regarding  the  functions  of  the  various  nerve-roots  which 
constitute  the  crural  plexus. 

These  conclusions  are  derived  from  two  methods  of  research 
— the  experimental  and  the  clinical — and  hitherto  they  have  not 
been  verified  by  any  accurate  anatomical  investigations  corre- 
sponding to  those  of  Herringham  upon  the  roots  of  the  brachial 
plexus. 

Drs.  Ferrier  and  Yeo/  observing  the  effects  of  experimental 
irritation  of  the  several  roots  of  the  crural  plexus,  classify  as 
follows  the  muscles  supplied  by  each  : — 

Third  lumbar  type : — Ilio-psoas,  sartorius,  adductors,  extensor 
cruris. 

Fourth  lumbar  type: — Extensors  of  thigh,  extensor  cruris, 
peroneus  longus,  adductors. 

Fifth  lumbar  type: — Flexors  and  extensors  of  toes,  tibial 
muscles,  sural  muscles,  peroneal  muscles,  outward  rotators  of 
thigh,  hamstrings. 

First  sacral  type : — Muscles  of  calf  (plantar  flexors),  ham- 
strings, long  flexor  of  big-toe,  intrinsic  muscles  of  the  foot. 

Second  sacral  type : — Intrinsic  muscles  of  the  foot. 

The  objections  to  an  implicit  reliance  upon  these  experimental 
results  have  been  already  indicated  in  considering  the  analogous 

^  Brain,  vol.  iv.,  1882,  p.  226. 


INJURIES    OF   THE   LUMBO-SACEAL   REGION. 


109 


observations  upon  the  brachial  plexus,  but,  as  in  the  latter  case, 
we  find  that  they  agree  in  the  main  with  the  results  of  clinical 
experience. 

The  classification  of  Dr.  Gowers  ^  is  derived  from  a  comparison 
with  the  above  of  such  scattered  clinical  records  as  throw  any- 
light  upon  the  distribution  of  functions,  and  the  results  thus 
obtained  are  embodied  in  the  following  Table  : — 


Motor. 


Sensory. 


Reflex. 


First  lumbar 
Second  lumbar 

Third  lumbar 

Fourth  lumbar. 

Fifth  lumbar 

First  sacral 

Second  sacral 
Third  sacral 
Fourth  sacral 

Fifth  sacral 
Coccygeal     . 


)  Cremaster. 
J  Flexors  of  hip. 

}  Extensors  of  knee. 
Adductors  of  hip. 
)  Extensors    and    ab- 
j      ductors  of  hip. 

>  Flexors  of  knee. 

}  Intrinsic  muscles  of 
foot. 
)  Perineal    and    anal 
)      muscles. 


W- 


§3 


\  Groin  and  scrotum 
)  (front). 

!(  Outer 
I  side. 
Thigh  <  Front. 
I  Inner 
\  side. 
Leg  (inner  side). 

Buttock  (lower  part ) 
Back  of  thigh. 
Leg  and  foot   ex- 
cept inner  part. 
J-  Perineum  and  anus. 

)  Skin  from  coccyx  to 
J      anus. 


Gluteal. 

\Foot- 
(     clonus. 
■ '  Plantar. 


If,  now,  we  endeavour,  as  in  the  cervical  region,  to  obtain  from 
an  examination  of  cases  of  spinal  injury  fresh  data  for  accurate 
localisation,  we  at  once  find  ourselves  confronted  by  several  difii- 
culties  which  render  useless  the  method  pursued  in  the  earlier 
investigation.  In  the  first  place,  death  comparatively  rarely 
follows  injuries  in  the  lumbar  region,  so  that  we  have  not  the 
advantage  of  an  absolutely  accurate  localisation.  The  cases  also 
which  are  met  with  in  an  individual  experience  are  too  few  for 
generalisation.  Again,  owing  to  the  fact  that  the  whole  of  the 
nerves  of  the  lumbo-sacral  plexus  originate  from  the  spinal  cord 
within  the  short  vertical  extent  of  the  last  dorsal  and  first  lumbar 
vertebree,  it  is  practically  impossible  to  find  spinal  injuries  which 
accurately  cut  off  their  separate  levels  of  origin.  And,  finally, 
most  important  of  all,  is  the  fact  that  the  nerve-roots  of  the  lower 
portion  of  the  cord  have  so  extensive  an  intraspinal  course  that 
they  are  generally  implicated  together,  and,  owing  to  the  solidity 
of  the  sacrum,  do  not  become  separately  cut  off  by  lesions  near 
their  points  of  exit. 

But,  in  spite  of  these  difficulties,  it  is  possible,  by  a  careful 
comparison  of  cases,  to  obtain,  from  the  evidence   supplied  by 

^  Diseases  of  the  Nervous  System   vol.  i.  p.  142. 


I  I O  SURGERY   OF   THE   SPINAL   CORD. 

spinal  injuries  alone,  a  fairly  accurate  conception  of  the  functions 
of  each  of  the  nerve-roots  which  enter  into  the  lumbar  and  sacral 
plexuses.  The  following  cases,  partly  original  and  partly  quoted, 
are  intended  to  illustrate  these  functions,  and  will  be  found  to 
supply  a  tolerably  complete  picture  of  the  effects  produced  by 
their  loss. 

As  in  nearly  all  these  cases  the  lesion  was  so  situated  that  all 
the  nerves  of  the  cauda  equina  might  possibly  have  been  affected, 
it  will  be  necessary  to  make  certain  assumptions,  viz.,  first,  that  if 
alter  a  crush  of  the  cauda,  certain  fibres  are  injured  and  others 
not,  the  injured  nerves  originate  lower  that  those  which  are 
spared ;  and  second,  that  where  destruction  of  certain  functions 
is  partial  only,  then,  the  more  complete  such  destruction,  the 
lower  is  the  nerve  whose  injury  has  given  rise  to  it.  The 
ground  for  these  assumptions  is  that,  as  a  matter  of  fact,  we 
seldom  find  nerves,  known  to  arise  high  up  in  the  crural  region, 
injured  whilst  those  below  them  have  escaped, — a  general  pro- 
position for  which  the  evidence  will  be  found  in  the  preceding 
chapter  (p.  99). 

It  will  again  be  convenient  first  to  present  in  tabular  form  the 
results  at  which  I  have  arrived,  and  then  to  consider  in  detail  the 
evidence  upon  which  the  conclusions  are  based.  In  the  Table 
thus  given,  it  is  to  be  distinctly  understood  that  I  have  inserted 
only  so  much  of  the  distribution  of  each  root  as  is  illustrated  by 
the  following  cases.  Thus,  although  there  is  no  doubt  whatever 
that  the  second  lumbar  root  supplies  muscular  branches,  these 
are  here  ignored  because  the  cases  yield  no  evidence  of  the  same. 
The  separation  of  some  of  the  roots  will  be  seen  to  be,  to  a  certain 
extent,  arbitrary,  and  it  is  not  improbable  that,  owing  to  the 
physiological  requirements  of  the  lower  limb,  the  specialisation  of 
the  spinal  nuclei  and  the  concomitant  isolation  of  their  efferent 
motor  fibres  are  less  marked  than  in  the  case  of  the  upper 
extremity,  and  that  I  may  thus  have  ignored  minor  nervous 
connections  running  in  roots  other  than  those  which  supply  the 
chief  motor  branches  to  each  muscle ;  but,  as  already  suggested, 
it  is  probable  that  this  very  absence  of  accurate  detail  itself 
renders  the  results  of  the  more  value  as  a  practical  clinical  guide, 
for  which  purpose  we  require  to  know  only  such  relationships  as 
will  influence  the  production  of  symptoms. 


INJURIES    OF   THE   LUMBO-SACEAL   REGION. 


I  I  I 


Root. 

Jlotor  Distribution. 

Sensory  Distribution. 

First  lumbar   .     .     . 
Second  lumbar     .     . 
Third  lumbar  .     .     . 

None. 

None. 

Sartorius. 

Adductors  of  thigh. 
Flexors  of  thigh. 

Ilio- hypogastric  and  ilio-in- 
guinal. 

Outer  (?)  and  upper  part  of 
thigh. 

Anterior  aspect  of  thigh  be- 
low second  lumbar  root. 

Fourth  lumbar    .     . 

Extensors  of  knee. 
Abductors  of  thigh. 

Anterior  and  inner  part  of 
leg. 

Fifth  lumbar  .     .     . 
First  sacral    .     .     .  \ 

Second  sacral     .     .] 

Hamstring  muscles. 

r  Calf  muscles. 

Glutei.  _ 
J  Peronei. 
1  Extensors  of  ankle.i  "j 

Intrinsic  muscles  of  }-  " 
I.      foot.                        J 

ID 

c 
.to 

Back  of  thigh,  except  in  dis- 
tribution of  first,  second, 
and  third  sacral. 

A  narrow  strip  on  back  of 
thigh,   back   of  leg,  and 
ankle  ;  sole  ;  part  of  dor- 
sum of  foot. 

Third  sacral    .     .     . 

Perineal  muscles 
(erector     penis,    transv 

salis  perinei,  accelera 

urinae,  &c.). 

er- 
tor 

Perineum,  external  genitals, 
"saddle-shaped"  area  of 
back  of  thigh. 

Fourth  sacral  .     .     . 

Bladder  and  rectum. 

Case  33. — Fracture  of  first  lumhar  vertebra — Crush  of  conus 

meduUafis. 

One  of  the  least  extensive  lesions  produced  by  injury  to  the 
lumbar  cord  is  that  found  in  the  following  case,  recorded  by 
Kirchhoff.' 

A  man,  aged  thirty,  fell  sideways  from  a  horse  on  to  his 
nates.  As  a  result  of  this  accident,  he  was  at  first  unable  to 
walk,  and  was  confined  to  bed  for  three  months.  During  the 
first  three  weeks  he  had  retention,  and  thereafter  incontinence  of 
urine,  with  cystitis.  He  suSered  also  from  involuntary  and  un- 
conscious defsecation.  After  some  nine  months  he  grew  gradually 
better,  until  he  could  remain  on  his  legs  all  day,  but  there  was 
no  material  change  in  the  condition  of  his  bladder  and  rectum. 
At  the  end  of  eighteen  months  he  was  seen  by  Kirchhofif.  At  that 
period  he  presented  tenderness  and  some  deformity  over  the  first 

*  Here,  as  elsewhere,  the  term  "extensors  of  the  ankle"  is  used  in  reference  to 
the  anterior  muscles,  i.e.,  the  extensors  in  a  morphological  sense. 
^  Arch,  fur  Psychiatric,  vol.  xv.  p.  607. 


I  1 2  SURGERY    OF    THE    SPINAL    CORD. 

lumbar  spine.  The  walk  was  slow  and  straddling  (vjeitbeinig), 
motor  and  sensory  power  were  preserved  throughout  the  body, 
but  all  four  Kmbs  were  weak.  The  patellar  reflexes  were  a 
little  exaggerated.  With  these  symptoms  he  had  loss  of  control 
over  the  bladder  and  rectum.  After  complete  emptying  of  the 
former  (by  the  catheter),  urine  was  retained  for  some  two  hours, 
but  incontinence  then  ensued.  If  the  faeces  were  fluid,,  they 
could  not  be  retained  at  all;  but  if  solid,  he  could  hold  them 
until  the  bed-pan  was  brought.  Cystitis  was  followed  by  pyelitis, 
secondary  abscesses,  and  death. 

At  the  autopsy  was  found  a  crush  of  the  first  lumbar  vertebra. 
The  discs  above  and  below  it  met  in  front,  and  the  body  was 
driven  backwards  in  the  form  of  a  triangle,  which  projected  about 
I  cm.,  compressing  the  lower  end  of  the  cord  some  3  cm.  above  the 
filum  terminale.  The  conus  medullaris  was  also  forced  to  the  ri^ht 
of  the  displaced  bone.  Microscopical  examination  showed  de- 
generation of  the  conus  medullaris  and  ascending  degeneration 
of  the  cord,  but  no  injury  to  the  fibres  of  the  cauda  equina. 
Besides  these  changes,  there  were  the  ordinary  appearances  of 
pyelitis  and  metastatic  abscesses. 

In  the  above  case  we  find  a  practically  uncomplicated  lesion  of 
the  termination  of  the  spinal  cord,  whose  nerves  appear  to  supply 
the  bladder  and  rectum  only.  True,  there  would  seem  to  have 
been  originally  some  slight  injury  to  other  nerves  going  to  the 
lower  limbs,  but  the  effect  of  this  general  pressure  on  the  cauda 
was  almost  entirely  transient,  and  the  only  definite  result  was 
paralysis  of  the  sphincter  ani  and  of  the  detrusor  and  sphincter 
vesicae,  both  doubtless  due  to  the  mischief  done  to  the  termination 
of  the  cord.  That  the  detrusor  was  paralysed  is  shown  by 
there  being  pure  retention  of  urine  for  the  first  three  weeks, 
followed  by  incontinence  when  partial  recovery  permitted  of  some 
return  of  function.  It  is  impossible  to  derive  any  information 
as  to  the  relative  vertical  arrangement  of  the  reflex  centres. 

Now  the  absence  of  any  anaesthesia  about  the  perineum,  penis, 
or  scrotum,  and  the  negative  evidence  that  there  is  no  note  of 
any  interference  with  the  sexual  functions,  such  as  would  arise 
from  paralysis  of  the  muscles  of  this  region,  sufficiently  indicate 
that  the  majority,  at  any  rate,  of  the  fibres  of  the  pudic  nerve 
had  escaped  injury,  and  that  the  other  chief  branches  of  the 
sacral  plexus  had  done  so  is  obvious.  We  are  thus  driven  to 
localise  the  lesion,  in  this  case,  immediately  above  the  fourth 
sacral  nerve  or  its  point  of  origin,  because  the  pudic  and  the 


INJURIES    OF    THE   LUMBO-SACRAL   REGION.  I  1  3 

nerves  for  the  lower  limbs  receive  sucli  large  reinforcement  from 
all  the  roots  above  this  point,  that  we  can  hardly  imagine  a 
lesion  involving  the  third  sacral,  and  yet  giving  rise  to  such  slight 
symptoms.  For  the  present,  therefore,  we  may  assume  this  to 
be  illustrative  of  a  lesion  of  the  fourth  and  fifth  sacral  and  the 
coccygeal  nerves  only.  The  small  patch  of  anaesthesia  (in  the 
region  of  the  tip  of  the  coccyx)  and  the  paralysis  of  the  levator 
ani,  which  might  be  expected  to  result  from  injury  of  the  two 
latter  branches,  would  readily  escape  notice. 


Case  34. — Fradure  of  last  lumbar  vertehra — Compression  of 
Cauda  equina  hy  callus. 

Strikingly  similar  to  the  foregoing  is  the  following  case,  which 
was  treated  in  Mr.  Whitehead's  wards  in  the  Manchester  Infirmar}^. 

D.  E.,  a  collier,  aged  forty-nine,  was  at  work  in  a  coalpit 
towards  the  end  of  October  1885,  and  was  standing  upright 
when  an  unknown  weight  of  coal  fell  from  the  roof,  striking  him 
across  the  back  of  the'  hips.  He  became  immediately  paraplegic, 
and  afterwards  remained  in  bed,  without,  he  said,  undergoing  any 
improvement,  up  tO'  the  date  of  his  admission  to  the  Infirmary, 
some  seven  weeks  after  the  accident,  viz.,  on  December  24,  1885. 

On  admission,  he  appeared  very  ill,  and  the  whole  body  was 
much  wasted,  the  muscles  of  the  upper  limbs  being  as  atrophic 
as  those  of  the  lower,  except  that  the  nates  had  perhaps  chiefly 
suffered.  He  presented  no  cerebral  symptoms.  The  spine 
showed  no  deformity,  and  could  not  be  said  to  be  tender  at  any 
point,  although  there  was  vague  soreness  over  the  sacrum.  He 
complained  of  severe  neuralgic  pains,  shooting  down  the  backs  of 
the  thighs  and  legs  to  the  heels,  and  at  times  extending  from 
the  bladder  to  the  end  of  the  penis,  or  referred  to  the  sacrum. 
Pressure  on  either  sciatic  nerve,  between  the  tuber  ischii  and  the 
great  trochanter,  caused  intense  pain.  The  bladder  was  much 
distended,  and  there  was  a  constant  dribbling  flow  of  urine, 
accompanied  by  much  pain,  but  he  retained  some  power  of 
voluntarily  increasing  the  flow  by  great  efforts.  He  was  greatly 
troubled  by  constipation,  and  had  no  control  over  the  passage  of 
his  faeces.  Without  support  he  could  not  stand  at  all,  but,  with 
very  slight  assistance,  he  could  walk  with  a  sprawling,  hesitating 
gait,  and  in  bed  he  could  move  his  lower  limbs  in  all  directions. 

All  the  muscles  reacted  readily  to  the  faradic  current,  and 
presented  no  abnormality  with  the  galvanic ;  tactile,  thermal, 
and    muscular   sensibility   were   normal  everywhere ;  the  super- 

H 


114  SURGERY   OF   THE   SPINAL   CORD. 

ficial  reflexes  were  normal,  the  knee-jerks  slightly  exaggerated, 
but  there  was  no  ankle-clonus.  The  skin  of  the  whole  body 
was  covered  with  a  sour  perspiration,  and  that  over  the  sacrum 
was  red  and  inflamed.  The  temperature  was  normal:  pulse  78, 
full,  regular,  and  rather  compressible.  Urine  acid,  clear,  of  sp. 
gr.  1020,  and  without  albumin.  He  suffered  much  from  thirst. 
No  inquiry  was  made  as  to  the  sexual  functions. 

Treatment  consisted  in  complete  rest  in  the  supine  position, 
with  periodic  evacuation  of  the  bladder. 

On  the  evening  of  December  3  i ,  a  week  after  admission,  the 
temperature,  which  had  hitherto  been  normal,  rose  suddenly  to 
103.2°,  and  it  thereafter  remained  high.  At  the  same  time  the 
urine  became  alkaline  and  foul,  and  he  suffered  from  constant 
nausea  and  vomiting,  with  foul  tongue.  These  symptoms  were 
followed  by  fibrillar  tremblings  in  the  muscles  of  the  trunk  and 
limbs,  by  rapidly  increasing  and  intense  emaciation,  obstinate  in- 
somnia, foetid  sweating,  and  a  very  frequent  (180)  intermittent 
pulse.  On  January  1 8  he  became  violently  delirious,  and  lapsed 
into  a  "  typhoid "  condition,  with  a  running  uncountable  pulse, 
and  two  days  later  he  died. 

The  post-mortem  examination  was  made  by  Dr.  Harris,  then 
pathologist  to  the  Infirmary,  whose  report  states  that  on  opening 
the  spinal  canal  there  was  found  on  its  anterior  aspect,  projecting 
from  the  posterior  part  of  the  body  of  the  last  lumbar  or  first 
sacral  vertebra,  a  disc-shaped  bony  prominence  about  the  size  of 
a  marble.  Although  no  other  signs  of  fracture  were  to  be  found, 
this  was  taken  to  be  probably  due  to  callus.  This  nodule  com- 
pressed the  entire  cauda  equina  opposite  to  it — that  is,  some 
4^  inches  below  the  conus  medullaris — through  a  vertical  extent 
of  about  half  an  inch,  the  component  nerves  being  united  by  a 
delicate  and  vascular  newly-formed  connective  tissue.  The  spinal 
membranes  themselves  and  the  cord  were  healthy  throughout, 
there  being  no  meningeal  thickening  even  opposite  the  bony 
nodule.  Above  and  below  the  latter  the  nerves  of  the  cauda 
equina  presented  no  abnormality,  nor  was  any  change  detected  in 
the  sciatic  nerves,  either  with  the  naked  eye  or  with  the  microscope. 

The  bladder  cavity  was  abnormally  large,  although  not  very 
markedly  so,  its  walls  of  normal  thickness,  its  mucous  membrane 
pale  and  smooth,  except  at  the  posterior  part,  where  there  was  a 
small  recent  haemorrhage  in  the  submucous  tissue.  It  contained 
a  large  quantity  of  pale  slightly  turbid  urine.  The  ureters  were 
not  dilated.  Both  kidneys  were  much  enlarged — the  right  weigh- 
ing nine,  the  left  ten  ounces ;  their  capsules  peeled  readily,  but 


INJURIES    OF   THE   LUMBO-SACRAL   REGION.  I  I  5 

were  thickened,  and  throughout  their  substance  were  numerous 
minute  abscesses,  each  surrounded  by  a  dark  zone  of  haemor- 
rhage ;  the  pelves  were  normal.  The  aortic  valve  of  the  heart 
was  thickened  and  incompetent ;  both  this  and  the  mitral  valve 
showed  evidences  of  recent  endocarditis  ;  the  walls  of  both  ventri- 
cles were  of  normal  consistency,  but  thickened,  the  entire  heart 
weighing  1 3-^  ounces.    The  other  organs  of  the  body  were  healthy. 

Here,  then,  we  have  a  case  in  which  the  cauda  equina  was 
partially  compressed  about  the  level  of  the  last  lumbar  vertebra. 
From  this  resulted  severe  neuralgia  in  the  sciatic  and  pudic 
nerves,  and  weakness  of  some  of  the  muscles  of  the  lower  limbs, 
but  no  complete  paralysis  and  no  anaesthesia  of  the  limbs.  Follow- 
ing the  rule  to  which  we  have  already  referred,  that  the  lowest 
branches  of  the  cauda  suffer  most  in  a  general  pressure  lesion,  we 
find  a  complete  paralysis  of  the  sphincter  ani  and  of  the  nervous 
mechanism  of  the  bladder.  The  paralysis  was  here  evidently  due 
to  interference  with  the  peripheral  fibres,  and  not  with  the  nuclei. 
The  power  of  expelling  some  urine  by  voluntary  straining  was 
probably  due  solely  to  action  of  the  abdominal  muscles.  As 
in  Kirchhofi^s  case,  there  is  a  possible  doubt  whether  (ignored  on 
examination)  the  region  between  the  coccyx  and  anus,  usually  sup- 
posed to  be  supplied  by  the  coccygeal  nerve,  may  not  have  presented 
a  small  patch  of  anaesthesia,  but  certainly  there  was  no  loss  of 
sensation  in  the  perineum  or  limbs.  Hence,  then,  this  case  further 
indicates  that  the  branches  for  the  sphincter  ani  and  the  bladder 
muscles  have  a  lower  origin  than  those  supplying  the  skin  and 
muscles  of  the  perineum.  There  are  several  points  in  the  case  not 
inquired  into  so  fully  as  might  be  wished,  due  to  the  fact  that  in 
1885  my  attention  had  not  been  directed  to  the  details  of  the  subject. 


Case  35. — Injury  to  cauda  equina  (?) — Paralysis  ofhladder 
and  sphincter  ani. 

On  March  16,  1887,  I  saw,  with  Mr.  George  Thomas,  of 
Bradford,  T.  0.,  thirty  years  of  age,  who  sustained  an  accident 
on  December  29,  1886.  On  that  date  he  was  standing  up 
in  a  cart,  when  a  van  ran  into  the  latter  from  behind,  throwing 
him  out  in  such  a  way  that  he  fell  upon  his  back  on  the  road, 
striking  the  lumbar  region  against  the  curbstone  of  the  pave- 
ment. He  was  able  to  get  up  at  once  and  to  walk,  but  says  that 
his  legs  felt  stiff  and  trembled.  Shortly  afterwards  he  walked 
up  some  stairs  to  the  top  of  a  warehouse,  and  he  drove  home. 


Il6  SURGERY    OF   THE    SPINAL   CORD. 

On  reaching  his  home  he  went  to  bed,  and  during  the  day  the 
lower  limbs  became  partially  paralysed,  as  they  have  since  re- 
mained. From  that  time  until  I  saw  him  he  had  been  bedridden, 
but  had  undergone  little  or  no  change  except  general  loss  of  flesh 
from  confinement.  At  first  he  had  severe  pain  in  the  lumbar 
region,  but  in  a  few  weeks  this  diminished,  and  in  March  1887 
he  had  only  some  aching,  mainly  when  sitting  up. 

On  examination,  he  was  found  to  present  partial  paralysis  of 
the  lower  limbs.  He  could  get  out  of  bed  and  across  the  room 
by  means  of  supports,  but  could  not  stand  if  unaided.  When 
lying  down,  he  moved  the  limbs  at  every  joint,  but  only  with 
great  effort  and  to  no  very  great  extent.  There  was  no  marked 
wasting  of  the  muscles.  He  stated  that  ten  years  previously  he 
had  had  a  fall,  ever  since  which  his  right  foot  had  "  dropped  a 
little."      He  believed  the  weakness  of  the  limbs  to  be  increasing. 

There  was  nowhere  any  anaesthesia.  The  knee-jerk  and  ankle- 
clonus  were  much  exaggerated,  the  plantar  reflex  normal,  the  cre- 
masteric absent.  He  complained  of  his  legs  occasionally  "jump- 
ing "  at  night. 

His  urine  ran  away  from  him  almost  constantly,  but  was  not 
foetid  ;  bladder  dulness  extended  from  the  pubes  to  the  umbilicus. 
He  knew  when  he  was  about  to  pass  his  fseces,  but  could  not 
retain  them,  and  must  at  once  obey  the  call  to  stool.  He  had 
no  priapism,  nor  any  trace  of  trophic  lesions,  and  erections  of 
the  penis  occurred  as  usual. 

Locally  there  was  no  deformity,  but  some  tenderness  of  the 

spine,  most  marked  opposite  the   level  of  the  posterior  superior 

iliac  spines.      The  general  health  had  remained  fairly  good. 

Mr.  Thomas  has  kindly  endeavoured  to  obtain  some  information  for  me  as  to  the 
subsequent  progress  of  this  case,  but  has  been  unable  to  hear  anything  very  definite. 
The  bladder  and  rectal  symptoms  appear  to  have  undergone  no  improvement,  but  the 
paresis  passed  off,  and  no  further  troubles  have  supervened.  In  the  summer  of 
1888  he  was  farming  near  Chester,  and  "looked  fairly  well." 

Hence  in  this  case  also  the  entire  cauda  equina  would  seem 
to  have  been  temporarily  injured  as  regards  the  motor  power  of 
its  nerves,  but  the  only  permanent  trouble  was,  as  in  Kirchhoff's 
case,  the  interference  with  the  bladder  and  rectum,  supplied  by 
the  lowest  roots.  The  case  is,  however,  not  satisfactory  evidence, 
as  the  lesion  may  have  been  a  slight  transverse  myelitis  in  the 
upper  lumbar  region. 

We  may  next  refer  to  a  group  of  cases  in  which  the  above- 
described  symptoms  were  present,  but  were  accompanied  by  other 
phenomena,  indicating  a  somewhat  higher  lesion. 


INJURIES    OF   THE   LUMBO-SACRAL   REGION. 


117 


Case  3  6. — Injury  of  the  cauda  equina  involving  the  third 
sacral  nerves. 

Huber  ^  reports  the  following  case  : — 

A  man,  aged  twenty-four,  fell  some  six  yards  on  to  a  paved 
street,  alighting  in  a  sitting  position.  He  immediately  felt  great 
pain  in  both  tubera  ischiorum,  in  the  lumbar  region,  over  the 
sacrum  and  along  both  sciatic  nerves,  and  he  could  not  stand. 
From  the  moment  of  the  accident  he  had  retention  of  urine,  with 
involuntary  evacuation  of  faeces,  accompanied  by  obstinate  con- 
stipation. He  could  hardly  move  his 
legs,  and  had  a  feeling  of  numbness 
in  them.  The  sacral  and  gluteal 
regions  were  very  tender.  After  about 
a  month  he  could  stand  and  walk, 
and  at  that  time  he  came  under 
Huber's  observation.  He  then  com- 
plained of  retention  of  urine,  inconti- 
nence of  faeces,  slight  weakness  of  both 
lower  limbs,  and  numbness  in  the 
soles  of  the  feet.  Great  flexion  of  the 
hips  caused  pain  from  the  exit  of  the 
sciatic  to  the  middle  of  the  thighs. 
There  was  no  paralysis  of  either  limb, 
and  the  reflexes  (superficial  and  deep) 
were  all  normal.  He  was  found  to 
have  anaesthesia  about  the  anus  and 
seat,  in  the  perineum,  scrotum,  and 
penis,  and  on  part  of  the  posterior  sur- 
face of  the  upper  part  of  the  thighs. 
The    boundaries    of  this    region   were 

not  sharply  defined,  and  will  most  readily  be  understood  from 
the  accompanying  representation  of  Huber's  diagram  (fig.  1 8), 
which  by  the  degree  of  shading  indicates  the  varying  intensity 
of  the  anaesthesia.  Although  the  scrotum  was  anaesthetic,  the 
testes  were  not.  There  was  very  dull  sensation  on  passing  the 
catheter  or  introducing  the  finger  into  and  pressing  upon  the 
rectum.  An  ill-defined  sensation  was  noticed  before  faeces  were 
passed.  The  walk  was  normal  and  without  pain.  He  could 
bend  the  back,  but  on  bending  the  knees  had  slight  pain  in  the 
calves.  There  was  no  deformity  of  the  back.  Some  three 
^   Wiener  medizinitche  Wochenschrift,  i8S8,  Xos.  39  and  40. 


Fig.  18. 


ii8 


SURGERY   OF   THE   SPINAL   CORD. 


months  after  the  accident  it  became  unnecessary  to  use  the 
catheter,  as  the  patient  could  by  strong  pressure  on  the  bladder 
cause  the  urine  to  flow  slowly.  He  had  sometimes  partial  erec- 
tions of  the  penis — not,  he  thought,  sufficient  for  copulation — 
and  two  or  three  times  there  was  an  escape  of  semen  with  slight 
voluptuous  sensation,  there  being  no  ejaculation,  but  only  a  slow 
escape  from  the  urethra. 

Huber's  diagnosis  is  intra-meningeal  hsemorrhage  below  the 
lumbar  enlargement,  which  for  a  short  time  compressed  the  cord 
itself,  causing  the  paralysis,  and  is  still  pressing  on  the  roots  of 
the  pudic  and  coccygeal  nerves,  as  well  as  on  the  lower  roots  of 
the  sciatic  nerve,  which  furnish  the  small  sciatic  branch,  the 
latter  being  less  affected  than  the  pudic  and  coccygeal.  There 
was  no  evidence  of  fracture,  and  the  immediate  onset  and  other 
symptoms  negative  myelitis. 


Case  37, — Injury  in  lumbar  region,  involving  the  third  sacral  roots. 

A  very  similar  case  is  related  by  Bernhardt :  ^ — 

On  January  10  a  patient  fell  on  to  his 
seat  from  the  second  floor  of  a  building, 
and,  not  losing  consciousness,  complained 
only  of  pain  in  the  back  and  retention  of 
urine.  On  the  following  day  he  had  to  be 
catheterised,  and  he  passed  his  fasces  in- 
voluntarily and  unconsciously.  Nine  days 
later  he  could  stand  alone,  but  had  pain 
from  about  the  seventh  to  the  twelfth  dorsal 
vertebra,  where  there  was  some  swelling 
and  tenderness.  He  had  still  retention  of 
urine  and  unconscious  defaecation.  There 
was  no  paralysis  of  the  lower  limbs,  the 
superficial  and  deep  reflexes  were  normal, 
and,  except  in  one  region,  sensation  to  all 
varieties  of  impression  was  normal.  Ana3S- 
thesia  was,  however,  complete  in  the  peri- 
neum, scrotum  (but  he  could  feel  pressure 
on  the  testicles),  penis,  over  the  lower  part 
of  the  sacrum  and  coccyx,  and  thence  out- 
wards for  about  a  hand's-breadth,  as  well  as  down  a  strip  on  the 
inner  and  posterior  aspect  of  the  thighs,  indicated  in  the  accom- 
*  Berliner  klinischc  Wochenschrift  August  6,  1888. 


Fio.  19. 


INJURIES   OF   THE   LUMBO-SACRAL   REGION.  I  1 9 

panying  figure  (fig.  1 9).  The  patient  continued  to  use  the  catheter, 
but  had  no  sensation  of  the  bladder  being  full.  He  could  feel  by 
abdominal  movements  when  he  passed  fseces,  but  did  not  feel 
their  course  through  the  rectum  or  anus.  He  had  sometimes  erec- 
tions, and  once  a  pollution,  and  in  February  he  performed  coitus. 
By  May  he  could  sometimes  pass  a  little  urine,  but  never  com- 
pletely emptied  the  bladder,  and  if  he  was  not  catheterised  the 
latter  would  ultimately  become  over-full,  and  urine  would  flow. 
On  the  1 2th  of  May  he  found  that  on  coitus  the  act  was  normally 
performed,  except  that  the  semen  was  retained  in  the  urethra, 
and  only  escaped  in  drops  some  time  afterwards.  An  electric 
current  was  not  felt  in  the  perineum,  urethra,  or  rectum,  nor 
could  any  contractions  be  felt  by  the  finger  in  the  levator  ani  or 
perineal  muscles.  After  continued  electrisation  of  these  parts 
there  was  some  improvement  in  the  power  of  passing  urine  and 
retaining  faeces. 

What  the  exact  nature  of  the  lesion  in  this  case  might  be 
could  not  be  ascertained  without  a  post-mortem  examination. 
Bernhardt  insists  mainly  on  the  fact  that  while  the  nervous 
supply  to  the  bladder  and  rectum  was  almost  absolutely  de- 
stroyed, that  of  the  genital  system  was  but  little  affected.  The 
nervi  erigentes  were  uninjured,  and  so  perhaps  was  the  nerve  to 
the  erector  penis ;  sexual  pleasure  was  also  retained,  but  impo- 
tence resulted  from  the  loss  of  expulsive  power — that  is,  from 
paralysis  of  the  accelerator  urinae  and  transversalis  perinei 
muscles. 

Two  other  cases,  recently  published  by  Oppenheim  and  by 
Osier,  still  further  illustrate  this  group  of  symptoms. 


Case  38.'' — Fracture  of  first  lunibar  vertebra — Crush  of  cord 
about  level  of  origin  of  third  sacral  roots. 

A  man,  aged  twenty-four,  fell  from  the  second  floor  of  a 
house  on  to  his  sacrum.  After  a  brief  period  of  unconsciousness, 
he  noticed  numbness  and  paralysis  of  both  lower  limbs,  both  of 
which  symptoms  rapidly  passed  away.  He  had  immediate  reten- 
tion, followed  by  complete  incontinence  of  urine  and  faeces,  with 
unconsciousness  of  their  passage.  Neither  erections  nor  passage 
of  semen  ever  occurred  after  the  injury.  At  the  region  of  the 
first  and  second  lumbar  spinous  processes  was  some  angular 
curvature.      Of  the  muscles  of  the  lower  limbs,  those  of  the  calf 

^  Oppenheim,  Arcliiv  fiir  PsycMatrie,  Band  xx.  Heft  I. 


I20 


SURGERY   OF   THE   SPINAL    CORD. 


only  showed  very  slight  weakness ;  otherwise  there  was  no  loss 
of  power,  and  no  atrophy  or  electrical  change.  The  knee-jerk 
was  exaggerated,  but  there  was  no  ankle-clonus.  Anaesthesia 
affected  the  region  of  the  anus,  buttocks,  perineum,  scrotum,  and 
penis,  and  a  small  strip  on  the  inner  and  posterior  aspect  of  the 
upper  part  of  the  thighs :  above,  it  was  limited  by  a  line  about 
half-way  down  the  sacrum,  and  externally  it  extended  to  midway 
between  the  tuber  ischii  and  great  trochanter.  Cystitis  and  fever 
supervened,  the  patient  dying  about  three  months  and  a  half  after 
the  injury. 

At  the  post-mortem  examination  was  found  a  fracture  of  the 
first  lumbar  vertebra.  The  terminal  portion  of  the  conus  medul- 
laris  was  compressed,  showing  the  histological  appearances  of 
myelitis  with  haemorrhages,  and  the  lowest  sacral  roots  were 
degenerated.  The  remaining  roots  of  the  cauda  equina  were 
almost  absolutely  normal. 


Case  39.^ — Injury  in  lumbar  region  involving  third  sacral  roots. 

A  man,  aged  forty-seven,  fell  from   a   bridge   into  a  sitting 

posture,  and  at  first  sus- 
tained paralysis  of  the  legs, 
bladder,  and  rectum,  the 
paralysis  of  the  lower  limbs 
passing  off  gradually.  Six- 
teen years  after  the  injury 
he  had  slight  weakness  and 
atrophy  of  the  left  lower 
limb.  The  spine  presented 
no  local  signs  of  injury. 
He  had  no  control  over 
the  bladder  and  rectum, 
and  was  impotent.  The 
gluteal  and  cremasteric  re- 
flexes and  the  knee-jerk 
remained.  Anaesthesia  is 
represented  in  the  annexed 
copies  of  Osier's  diagrams 
(figs.  20  and  21),  and 
affected  the  lower  gluteal 
regions,  posterior  aspects  of  the  thighs,  perineum,  scrotum,  and 
penis  as  far  as  its  root.  The  urethra  was  also  insensitive. 
1  Osier,  Medical  News,  December  15,  1888. 


Fig.  20. 


Fio.  21. 


INJURIES    OF   THE   LUMBO-SACRAL   REGION.  I  2  I 

It  will  thus  be  seen  that,  just  as  our  three  first  cases  represent 
a  group  in  which  the  injury  is  of  the  slightest  nature,  and  pro- 
bably affects  only  the  terminal  roots  of  the  cord,  so  also  the  last 
four  form  another  group  in  which  we  have  the  same  vesical 
and  rectal  troubles  plus  paralysis  (in  the  male)  of  the  ejacula- 
torates  seminis,  with  anaesthesia  of  the  perineum  and  genital 
organs  and  of  a  patch  in  the  thighs,  which,  from  the  obvious 
coincidence  with  those  parts  of  the  thigh  which  come  first  into 
contact  with  a  small  saddle,  we  may  perhaps  call  the  "  saddle- 
shaped  "  type. 

We  find  then  in  our  second  group  destruction  of  function  of  the 
fourth  and  fifth  sacral  and  of  the  coccygeal  nerves,  together  with 
anassthesia  of  the  entire  cutaneous  distribution  of  the  pudic  nerve, 
and  of  part  of  that  of  the  small  sciatic  (especially  its  inferior  gluteal 
branch),  and  paralysis  of  some,  perhaps  all,  of  the  muscular 
branches  of  the  pudic  (running  to  the  transversalis  perinei,  erector 
penis,  accelerator  urinse,  and  compressor  urethrae).  May  we  not 
then  venture  to  assume  that  this  second  group  of  cases  represents 
the  effects  of  injury  to  the  third  sacral  and  subjacent  nerves,  the 
third  thus  being  the  root  which  supplies  the  bulk  of  the  pudic 
trunk,  and  a  portion  of  the  sciatic,  devoted  apparently  to  such  of 
the  cutaneous  distribution  of  the  small  sciatic  nerve,  as  has  been 
fully  described  ? 

In  these  cases  we  find  also  an  interesting  condition  of  the 
nervi  erigentes.  In  Case  36  these  nerves  were  apparently  par- 
tially paralysed  ;  in  Case  37  they  had  entirely  escaped  injury ;  and 
in  Case  38  they  were  totally  paralysed  (in  Case  39  we  have  no 
precise  information).  Dr.  Gaskell  has  localised  these  nerves  in  the 
second  and  third  sacral  roots,  a  conclusion  which  perfectly  explains 
the  varying  extent  of  the  injury  done  to  them  in  a  lesion  of  the 
third. 

Thus  far  we  have  referred  only  to  injuries  of  the  extreme  lower 
roots  of  the  sacral  plexus,  but  owing  to  the  obscurity  of  the  few 
recorded  cases  of  injury  or  disease  immediately  above  this  region, 
it  will  perhaps  be  better  now  to  turn  to  the  upper  limits  of  the 
lumbar  plexus,  and  to  trace  downwards  the  connecting  links 
which  lead  us  to  the  previous  groups.  I  have  no  instance  of  a 
lesion  immediately  below  the  first  lumbar  root,  but  it  is  not 
necessary  to  adduce  evidence  that  that  root  supplies  the  ilio- 
hypogastric and  ilio-inguinal  nerves.  To  what  extent  it  provides 
fibres  of  the  genito-crural  I  am  unable  to  say. 


122 


SURGERY   OF   THE   SPINAL   CORD. 


Case  40. — Dislocation  of  last  dorsal  vertebra — Paralysis  below 
second  lumbar  nerve-roots. 

T.  H.  was  admitted  into  the  Manchester  Royal  Infirmary,  under 
the  care  of  Mr.  Hardie,  on  January  16,  1888.  He  was  a  labourer, 
aged  thirty-nine,  and  was  loading  a  cart  when  a  bale  of  cloth  fell 
upon  his  shoulders,  doubling  him  up.  For  the  first  few  minutes 
he  was  unconscious,  and  then  found  that  he  had  lost  both  motion 
and  sensation  in  the  lower  limbs.  On  admission,  he  complained 
of  pain  in  the  lower  part  of  the  back  and  the  right  side  of  the 


Fio.  22. 


Fio.  23. 


chest,  pain  being  also  caused  in  the  lumbar  region  of  the  spine  on 
pressing  down  the  shoulders.  Two  of  the  lower  spinous  processes 
were  somewhat  prominent.  The  lower  limbs  were  entirely  para- 
lysed, but  there  was  no  affection  of  the  trunk  or  upper  extre- 
mities. He  had  anaesthesia  of  the  lower  limbs,  with  the  following 
boundaries : — In  front,  sensation  extended  accurately  to  the  line 
of  Poupart's  ligament,  except  that  on  the  outer  side  of  the  left 
thigh  there  was  a  patch  of  sensation  extending  downwards,  and  of 
about  the  size  and  shape  of  the  hand  with  the  fingers  held  down- 
wards. On  the  right  side  was  a  patch  of  similar  shape,  but  about 
twice  the  above  size,  and  extending  more  to  the  front  of  the  thigh. 


INJURIES    OF   THE    LUMBO-SACKAL   REGION. 


12 


The  penis  and  scrotum  were  also  anaesthetic,  except  at  the  upper 
part  of  the  latter,  i.e.,  in  the  distribution  of  the  ilio-in^uinal  nerve. 
Behind,  anaesthesia  was  limited  by  a  line  extending  from  the  upper 
part  of  the  great  trochanter  to  the  posterior  superior  spine  of  the 
ilium,  and  thence  to  the  middle  line.  The  annexed  diagrams  best 
illustrate  the  boundaries  of  the  affected  region  (figs.  22,  23).^ 

The  plantar  and  cremasteric  reflexes  were  absent,  as  were  also 
the  knee-jerks.  The  penis  was  turgid,  urine  was  retained,  and 
had  to  be  drawn  off  by  the  catheter ;  it  had  a  sp.  gr.  of  1 0 1 4, 
was  acid,  and  contained  no  albumin  or  sugar,  but  gave  a  deposit 
of  phosphates.  The  pulse  was  feeble, 
96  per  minute ;  temperature  99° ; 
respiration  somewhat  abdominal,  with 
bronchitis,  due  to  a  cold  which  had 
existed  before  the  accident. 

Three  days  after  admission  the  urine 
became  alkaline  and  foetid  and  con- 
tained blood,  which  was  present  for  a 
day  or  two  only,  and  was  then  replaced 
by  pus.  For  several  weeks  thereafter 
no  change  of  importance  occurred,  and 
the  general  condition  improved,  the 
bronchitis  passing  off,  and  the  cystitis 
varying  in  severity  from  time  to  time. 
Wasting  of  the  lower  limbs  came  on 
gradually,  and  two  months  after  the 
accident  their  muscles  were  all  found 
to  be  insensitive  to  the  faradic  current. 
The  feet  also  became  somewhat  oede- 
matous.  Turgidity  of  the  penis  still 
continued,  but  appeared  to  be  due  to  fjo-  =4 
irritation  from  use  of  the  catheter. 
About  this  time  the  patient  complained  of  great  loss  of  sight  in 
the  right  eye,  but  repeated  examinations  made  both  by  Dr.  Little 
and  myself  failed  to  show  any  abnormality,  either  organic  or 
functional,  with  the  exception  of  myopia.  During  the  next  month 
this  symptom  gradually  improved. 

On  May  1 6th,  when  I  last  saw  him,  he  had  been  very  ill  for 
several  days,  with  much  vomiting,  and  was  very  thin ;  his  nervous 
symptoms  presented  no  change  of  importance,  the  paralysis  and 
anaesthesia  being  the  same  as  on  admission.  The  urine  constantly 
dribbled  away  from  him,  was  very  foetid,  and  contained  much  pus. 

^  In  fig.  22  the  unshaded  or  sensitive  area  is  carried  too  low  on  the  left  side. 


Fracture  of  first  lumbar  and 
dislocatiou  of  last  dorsal  vertebra. 


124  SURGERY    OF   THE   SPINAL   CORD. 

Four  days  later  he  died  exhausted.     The  temperature  throughout 
the  case  was  usually  slightly  raised. 

The  post-mortem  examination  was  made  by  my  clerk,  Mr. 
Hopkinson,  who  removed  several  of  the  vertebrae,  from  a  sagittal 
section  of  which  is  taken  the  annexed  sketch  (fig.  24).  The 
latter  shows  a  fracture  of  the  first  lumbar  vertebra  with  disloca- 
tion forwards  of  the  last  dorsal.  The  lower  part  of  the  spinal  cord 
and  the  trunks  of  the  cauda  equina  were,  after  death,  not  markedly 
compressed  by  the  projection  backwards  of  the  former  bone.  In 
the  bodies  of  both  vertebrae  were  changes  due  to  chronic  osteo- 
myelitis, but  there  was  no  trace  of  callus. 


Case  4 1 . — Dislocation  of  last  dorsal  vertebra — Paralysis  beloio 
second  lumbar  nerve-roots. 

L.  L.,  aged  thirty-seven,  a  collier,  was  admitted  to  the  Man- 
chester Royal  Infirmary,  under  the  care  of  Mr.  Heath,  on  Feb- 
ruary 21,  1888.  Shortly  before  admission  he  had  been  working 
in  the  pit  when  a  portion  of  the  roof,  of  which  he  judged  the 
weight  to  be  about  two  tons,  fell  upon  him,  striking  his  left 
shoulder  and  bending  him  forwards,  so  as  to  double  him  up. 
He  was  immediately  paralysed,  but  did  not  lose  consciousness. 

On  the  following  day,  when  I  examined  him,  he  complained 
of  pain  in  the  belly  and  back,  and  of  loss  of  power  and  sensation 
in  the  lower  limbs.  He  had  also  the  effects  of  a  severe  bruise 
on  the  left  shoulder.  Over  the  lower  dorsal  and  upper  lumbar 
region  was  found  a  somewhat  extensive  depression,  but  the  exact 
outline  of  the  bones  was  masked  by  effused  blood.  In  this  region 
he  complained  of  great  pain  and  tenderness,  but  he  had  no  pain 
on  jerking  the  spine  from  above.  The  lower  limbs  were  abso- 
lutely paralysed,  but  the  thoracic  and  abdominal  muscles  as  well 
as  those  of  the  upper  limbs  had  escaped  injury.  The  limitation 
of  anaesthesia  was  not  very  distinct ;  "  it  appeared  to  extend  over 
all  nerves  below  the  last  dorsal,  except  that  in  the  distribution 
of  the  ilio-inguinal,  ilio-hypogastric,  genito-crural  and  external 
cutaneous  there  rernained  some  vague  sensation."  About  the 
level  of  the  ilio-hypogastric  and  last  dorsal  was  slight  hyperaes- 
thesia.  The  knee-jerk  and  the  plantar  and  cremasteric  reflexes 
were  absent.      All  these  symptoms  were  symmetrical. 

The  urine,  which  was  retained,  and  had  to  be  withdrawn  by  the 
catheter,  had  a  sp.  gr.  of  1030,  was  loaded  with  urates,  contained 
a  little  albumin,  and  gave  a  very  well-marked  sugar  reaction. 


INJURIES    OF   THE   LUMBO-SACKAL    REGION. 


12 


The  penis  was  slightly  turgid.  He  had  had  some  bronchitis  before 
the  accident,  and  had  at  this  time  a  bad  cough,  the  chest  move- 
ments being  feeble.  Temperature,  100°;  pulse,  80;  pupils, 
somewhat  dilated. 

On  the  following  day  the  line  of  demarcation  of  the  anresthesia 
was  better  marked,  and  its  distribution  was  found  to  be  on  both 
sides  almost  identical  with  that  represented  on  the  right  limb  in 
figs.  22  and  23.  The  urine  contained  less  albumin  (there  being 
a  scarcely  perceptible  trace),  and  no  sngar. 

For  some  days  there  was  no  marked  change.  The  cough  im- 
proved slightly.  The  urine  became  alkaline  and  foetid,  and  on 
February  28  contained  swarms  of  micro- 
cocci, mostly  in  pairs  and  small  chains, 
but  no  pus.  The  anaesthesia  extended 
an  inch  or  so  upwards  on  the  abdomen, 
with  a  hypersesthetic  band  above  it.  On 
March  2  it  had  reached  to  a  line  2^ 
inches  above  the  umbilicus,  but  was  by 
no  means  complete  for  some  distance 
below  this  level.  The  bowels  were  at 
first  obstinately  confined,  but  after  the 
administration  of  croton  oil  on  February 
27,  faeces  were  passed  involuntarily. 
Pain  round  the  abdomen  was  so  great  as 
to  require  frequent  use  of  morphia  and 
belladonna  stupes.  The  temperature 
became  daily  a  little  higher,  reaching 
after  February  27  to  about  103°,  with 
no  marked  variations.  On  March  3  he 
was  obviously  sinking ;  his  cough  was  very  troublesome,  the 
bronchial  passages  much  obstructed,  and  the  temperature  fell 
three  degrees.      On  March  4,  the  twelfth  day,  he  died  exhausted. 

At  the  post-mortem  examination  we  found  the  disc  between 
the  twelfth  dorsal  and  first  lumbar  vertebrae  ruptured,  and  the 
anterior  part  of  the  latter  vertebra  broken  away  obliquely,  as 
shown  in  the  accompanying  engraving  (fig.  25).  The  spines  of 
these  two  vertebrae  were  separated  behind,  owing  to  the  twisting 
forwards  of  the  last  dorsal,  but  there  was  not  at  the  time  of 
the  autopsy  any  displacement  sufllcient  to  narrow  the  spinal  canal. 
The  pedicles  of  the  twelfth  dorsal  vertebra  were  also  broken  across, 
but  without  displacement  of  its  arch,  and  its  articular  processes 
were  separated  from  those  of  the  first  lumbar.  The  dura  mater 
was  intact,  and  the  cord  and  cauda  equina  not  compressed,  nor 


Fig.  25. — Fracture  of  first  hunbar 
ami  disiociitiou  ol  last  dorsal  ver- 
tebra. 


126  SURGERY   OF   THE    SPINAL    CORD. 

was  there  any  hsemorrliage  into  the  spinal  canal.  The  cord  was, 
however,  quite  soft  at  the  seat  of  the  lesion,  and  for  some  two 
inches  above  it. 

In  these  two  cases  we  have  complete  paralysis  of  the  crural 
plexus,  except  that  certain  sensory  nerves  have  escaped.  The 
skin-area  thus  spared  is  represented  by  figs.  22  and  23,  and  it 
will  be  found  that  the  nerves  not  interfered  with  are  the  ilio- 
hypogastric and  ilio-inguinal,  which  undoubtedly  arise  from  the 
first  lumbar  root ;  together  with  a  part  of  the  distribution  of  the 
genito-crural,  arising  from  the  first  and  second  lumbar,  and  of 
the  external  cutaneous,  which  arises  from  the  second  and  third 
lumbar.^  The  lesion  in  each  case  may,  therefore,  probably  be  sup- 
posed to  be  beneath  the  second  lumbar  nerve,  which  will  perfectly 
explain  the  sensory  effects.  We  should  expect  the  testicles  also 
to  be  sensitive,  owing  to  the  distribution  to  them  of  the  genital 
branches  of  the  genito-crural,  but,  unfortunately,  this  point  was 
not  investigated  in  either  case.  They  have,  however,  been  found 
to  retain  sensation  in  several  cases  of  injury  at  slightly  lower 
levels.  There  is  no  evidence  that  any  muscles  supplied  by  the 
plexus  escaped  paralysis,  it  being  impossible  to  demonstrate  the 
functions  of  the  nerve  to  the  cremaster,  except  by  the  reflex,  which 
is  here  annihilated  by  the  angesthesia.  The  turgidity  of  the  penis 
noticed  in  both  cases  is  merely  the  semi-distended  condition  seen 
in  most  spinal  injuries,  and  is  quite  difierent  from  the  distension 
of  erection  such  as  may  occur  when  the  injury  is  below  the  level 
of  the  nervi  erigentes. 

We  are  thus  brought  downwards  to  the  level  of  origin  of  the 
third  lumbar  nerve-roots.  Below  this  region  I  have  no  cases  to 
offer  in  which  the  differentiation  of  roots  was  produced  by  a 
localised  crush  of  the  cord,  but  if  we  grant  the  original  postulate 
that  in  crushes  of  the  cauda  equina  the  most  i  njured  roots  are 
those  of  lowest  origin,  we  obtain  much  information  from  the  cases 
related  in  the  previous  chapter. 

Thus  in  Case  29  the  distribution  of  the  anaesthesia  indicates  a 
complete  paralysis  of  the  entire  sciatic  nerve,  and  of  all  the  nerve- 
roots  inferior  to  those  from  which  it  arises.  Hence  the  muscles 
partially  paralysed  are  presumably  supplied  by  the  third  and 
fourth  lumbar  roots,  the  chief  tributaries  of  the  anterior  crural. 
These  muscles  are,  in  the  order  of  increasing  severity  of  paralysis, 
as  follows : — 

^  In  referring  to  the  distribution  of  sensory  nerves,  I  have  used  Mr.  Wagstaffe's 
edition  of  Heiberg's  "  Atlas  "  (London,  1885). 


INJURIES    OF    THE    LUMBO-SACRAL   REGION.  12/ 

1 .  Flexors  of  the  thigh : — psoas,  iliacus,  with  assistance  of 
sartorius  and  rectus. 

2.  Adductors  of  the  thigh  and  extensors  of  the  knee  : — adductor 
group,  rectus  and  quadriceps  femoris. 

3.  Abductors  of  the  thigh  : — tensor  fasciae  and  fibres  of  the  glutei. 
If,  again,  we  compare  the  relative  strength  of  the  muscles  in 

Case  32,  in  which  the  lesion  was  similar,  we  have : — 

1 .  Adductors  of  thigh. 

2.  Flexors  and  extensors  of  thigh. 

3 .  Extensors  of  knee. 

4.  Abductors  of  thigh. 

In  both  cases,  then,  we  find  the  adductors  and  flexors  of  the 
thigh  retaining  more  power  than  the  extensors  of  the  knee  or 
abductors  of  the  thigh,  so  that  we  may  localise  the  nuclei  of  the 
adductors  and  ilio-psoas  higher  than  those  of  the  quadriceps, 
tensor  fasciae,  and  gluteus  maximus.  The  considerable  power 
retained  in  the  extensors  of  the  thigh  in  Case  32,  I  can — having 
regard  to  the  otherwise  demonstrated  interference  with  the  func- 
tions of  the  sciatic — only  regard  as  probably  due  to  an  error  of 
observation.  It  is  an  extremely  difficult  matter  to  estimate  the 
comparative  contractile  power  of  the  muscles  of  the  lower  limb, 
and  in  this  instance,  as  the  patient  could  only  be  satisfactorily 
examined  when  lying  on  his  back,  the  action  of  gravity  would  assist 
the  extensors  of  the  thigh  and  oppose  both  the  flexors  of  the  thigh 
and  extensors  of  the  knee. 

The  cases  tabulated  on  pp.  98,  100,  bear  out  this  arrangement, 
as  do  Cases  30  and  31,  the  diagrams  of  the  distribution  of  anses- 
thesia  in  the  two  latter  illustrating  the  sensory  distribution  of 
nerve-roots  below  the  fourth  lumbar. 

On  the  basis  of  the  above  results,  I  would  then  assign  to  the 
third  and  fourth  lumbar  roots  the  innervation  of  the  adductors, 
flexors,  and  abductors  of  the  hip-joint,  and  of  the  extensors  of 
the  knee-joint,  and  would  place  the  adductors  and  flexors  of  the 
thigh  at  a  higher  level  than  the  other  muscles  supplied  from 
the  anterior  crural,  so  that  probably  the  third' lumbar  root  sup- 
plies the  adductors  and  ilio-psoas,  the  fourth  lumbar  the  rectus, 
quadriceps,  and  tensor  fascia  femoris. 

The  position  of  the  sartorius  is  perhaps  determined  by  a  case 
of  spinal  injury  recorded  by  M'Donnell,^  in  which  the  muscles  of 
the  lower  limb  were  paralysed,  with  the  exception  of  those  of  the 
"  front  of  the  thigh,"  which  were  paretic  only,  and  of  the  sartorius, 
which  appeared  to  have  entirely  escaped  injury.  Hence  it  would 
^  Dublin  Quarterly  Journal  of  Medical  Science,  vol.  xlii.     Supra,  p.  102,  Case  H. 


128  SURGERY    OF   THE    SPINAL   CORD. 

appear  that  the  spinal  nuclei  for  this  muscle  must  be  assigned  a 
high  position  in  the  region  of  origin  of  the  third  lumbar  root. 

The  sensory  distribution  of  the  third  and  fourth  lumbar  roots 
is  best  illustrated  by  the  diagrams  of  retained  sensation  in  Cases 
30  and  31,  but  I  have  no  facts  which  assist  us  to  differentiate 
the  two  roots  satisfactorily.  In  Case  44,  recorded  below,  the 
method  of  disappearance  of  the  aneesthesia  would  seem  to  indicate 
that  the  plexus  patellee  (derived  from  the  obturator  nerve),  and 
the  long  saphenous,  arise  lower  than  the  middle  and  internal 
cutaneous  branches  of  the  anterior  crural. 

The  cremasteric  reflex  is  retained  when  the  third  and  fourth 
lumbar  roots  escape  paralysis,  but  lost  when  the  lesion  extends 
above  their  level  of  origin. 

Passing  on  now  to  the  consideration  of  roots  below  the  fourth 
lumbar,  we  find  that  in  Case  32,  where  these  inferior  roots  had 
partially  escaped  injury,  the  muscles  of  the  posterior  aspect  of  the 
thigh  retained  more  power  and  recovered  much  more  thoroughly 
than  those  of  the  leg  and  buttock.  We  are  thus  led  to  regard 
the  former  as  supplied  from  a  higher  point  in  the  cord,  and  we 
may  assign  them  to  the  fifth  lumbar  root,  which  gives  a  very  large 
branch  to  the  sciatic.  This  would  leave  us  with  the  first  and 
second  sacral  roots  for  the  supply  of  the  glutei  and  leg-muscles. 
Unfortunately  the  evidence  available  to  enable  us  thus  to  split  up 
the  functions  of  these  three  great  tributaries  of  the  sciatic  is  very 
scanty,  but,  such  as  it  is,  it  bears  out  the  above  view. 


Case  43. — Dislocation  of  fifth  Imnhar  vertebra — Injury  to  sacral 

nerve-roots. 

Kahler '  relates  the  case  of  a  young  man  who  had  fallen  a 
distance  of  about  nine  yards,  probably  on  to  the  buttocks.  The 
lower  limbs  were  at  first  completely  paralysed  and  anaesthetic, 
but  a  certain  amount  of  improvement  shortly  ensued,  so  that 
in  seven  months  he  could  walk  with  crutches.  After  that 
period  there  was  no  further  change.  When  examined  after  the 
lapse  of  two  years,  the  spine  showed  marked  lordosis,  the  second 
lumbar  spinous  process  was  in  its  normal  position,  the  third  was 
depressed,  and  the  fourth  still  more  so,  the  fifth  being  so 
deeply  seated  that  it  could  not  be  felt.  Various  details  given 
in  the  original  paper  show  clearly  that  the  fifth  lumbar 
^  Prager  medie.  Wochenschrift,  1882,  Nos.  35,  36,  and  37. 


INJURIES    OF    THE   LUMBO-SACRAL    REGION. 


129 


vertebra  was  dislocated  forwards  on  the  sacrum.  The  patient 
had  no  control  over  the  bladder,  which  was  much  distended, 
and  emptied  itself  involuntarily.  Defcecation  was  also  involun- 
tary. In  the  lower  limbs  the  adductors  of  the  thigh  and  the 
quadriceps  were  well  developed,  the  tensor  fasciae,  posterior 
thigh-muscles  and  glutei  were  much  wasted,  as  were  all  muscles 
below  the  knee,  those  of  the  calf  being  the  best  developed  of  the 
latter.  Both  feet  were  pointed.  Adduction  and  flexion  of  the 
hip  were  powerfully  performed ;  extension,  and  especially  abduc- 
tion, feebly  so.  Exten- 
sion of  the  knee  was 
well  performed;  flexion 
almost  impossible.  Ac- 
tive movements  of  the 
foot  and  toes  were 
totally  paralysed.  The 
peroneus  longus  and 
brevis,  the  tibialis 
antic  us,  and  the  ex- 
tensor communis  digi- 
torum  presented  the 
reaction  of  degenera- 
tion, but  the  rest  of 
the  above-mentioned 
muscles  (including  the 
glutei  and  gastroc- 
nemii)  did  not.  The 
knee-jerks  were  re- 
tained. Slight  ankle- 
clonuscouldbe  elicited, 
but  the  plantar  reflex 
was  lost.  The  sensory 
deficiency  is  best  in- 
dicated by  a  copy  of  Kahler's  diagrams  (Figs.  26  and  27). 

The  temperature  of  the  lower  limbs  was  the  same  as  that  of  the 
rest  of  the  body.  Over  the  gluteal  region  was  a  bed-sore,  but  no 
other  trophic  changes  presented  themselves. 

Kahler  regards  this  as  an  instance  of  injury  to  the  fifth  lumbar 
roots,  at  their  point  of  exit  between  the  last  lumbar  vertebra  and 
the  sacrum  ;  but  it  would  appear  to  the  writer  to  represent  rather 
a  crush  of  the  cauda  equina  at  this  level.  The  distribution  of 
the  anaesthesia  corresponds  to  an  injury  involving  the  pudic  nerves 
and  the  greater  part  of  the  area  supplied  by  the  sciatics,  and  the 


Figs.  26  and  27.— The  hyperfesthetic  area  is  shaded  with 
crosses  ;  the  region  of  total  anaesthesia  with  hnes  ;  in  the 
area  indicated  by  large  dots  there  was  loss  of  the  senses 
of  pain  and  of  temperature  only ;  in  that  of  the  small 
dots,  loss  of  temperature  sense. 


130  SURGERY    OF    THE   SPINAL    CORD. 

affection  of  the  bladder  and  rectum  also  show  the  lower  roots  to 
have  been  affected.  Taking  this  view,  we  can  arrange  the 
muscles  of  the  limb  in  the  order  in  which  they  suffered,  i.e., 
probably  in  the  order,  from  above  downwards,  of  the  origin  of 
their  nerve-fibres,  thus  : — 

1.  The  adductors  and  flexors  of  the  thigh  uninjured. 

2.  Extensors  and  abductors  of  the  thigh  weakened  and 
wasted.^ 

3.  Glutei  and  gastrocnemeii  paralysed  and  mucb  atrophied. 

4.  Peronei,  extensors  of  ankle  (and  intrinsic  muscles  of  foot  ?) 
entirely  paralysed,  and  presenting  the  reaction  of  degeneration. 

This  supposition  is  borne  out  by  the  ultimate  condition  of 
Case  32,  in  which,  after  recovery  of  the  other  muscles  supplied 
by  the  sciatic,  those  moving  the  ankles  and  toes  remained  para- 
lysed, and  by  Case  30,  where  the  sensory  paralysis  affected  the 
sciatic  and  pudic  nerves,  and  the  motor  paralysis  chiefly  the 
muscles  supplied  by  the  pudic  nerve  and  those  about  the  ankle. 
Eurther  confirmation  is  derived  from  the  following : — 


Case  44. — Injury  to  the  lower  (J  second)  sacral  nerve-roots. 

This  case  was  kindly  shown  to  me  by  Dr.  Jones,  of  Wath- 
upon-Dearne.  The  patient  was  a  collier,  aged  forty-six.  On 
March  15,  1887,  he  received  an  injury  to  his  spine,  being 
doubled  forwards  by  a  weight  falling  on  to  his  back.  His  lower 
limbs  were  paralysed  for  sixteen  weeks,  and  he  had  "  very  little  " 
feeling  in  them.  During  the  first  fortnight  his  urine  had  to  be 
drawn  off  by  the  catheter. 

When  I  saw  him,  eighteen  months  after  the  accident,  he  com- 
plained of  pain  and  a  burning  sensation  in  the  hips.  He  walked 
with  the  knees  bent,  throwing  his  weight  on  to  the  heels,  and 
he  could  not  raise  the  toes  of  the  left  foot  from  the  ground 
when  the  foot  was  kept  firm,  those  of  the  riglit  being  moved  with 
difficulty  only.  He  had  nowhere  any  anesthesia.  The  plantar 
reflex  was  lost,  the  cremasteric  retained  on  both  sides,  and  the 
knee-jerks  were  absent.  He  required  much  straining  to  pass 
water,  but  could  do  so  by  his  own  efforts.  There  was  no  rectal 
trouble,  and  coitus  was,  he  said,  normally  performed.     The  spinous 

'  The  nerves  to  these  muscles  pass  out  of  the  vertebral  canal  above  the  level  of  the 
lesion,  but  there  are  several  obvious  explanations  of  an  upwards  extension  of  the 
pressure  upon  the  cauda  equina. 


INJURIES    OF    THE    LUMBO-SAORAL    REGION.  I3I 

process  of  one  of  the  lumbar  vertebme,  apparently  the  first,  was 
displaced  about  half  an  inch  to  the  right  of  the  middle  line. 

Here  the  only  traces  of  paralysis  were  found  in  the  extensors 
of  the  toes  and  in  the  wall  of  the  bladder,  and  there  was  no 
anaesthesia. 

In  the  following  the  paralysis  was  almost  universal  in  the 
lumbo-sacral  plexus,  but  the  anaesthesia  produced  by  injury  to  the 
lower  nerve-roots  of  the  sciatic  is  well  indicated. 


Case  4  5 . — Dislocation  of  last  dorsal  vertebra — Paraplegia — 
Partial  ancesthesia —  Trephining. 

J.  M.,  aged  twenty-eight,  a  pattern-maker,  was  admitted  to 
Mr.  Jones's  wards  on  March  9,  1888.  A  few  minutes  before 
he  was  brought  in,  some  iron  plates,  which  he  estimated  to  weigh 
about  10  cwts.,  had  fallen  on  to  his  shoulders,  bending  him 
forwards.  He  resisted  their  weight,  but  was  gradually  forced 
down  until  the  plates  were  held  up  by  some  bystanders,  just  before 
he  came  to  the  ground.  He  was  at  once  deprived  of  all  power 
of  motion  and  sensation  in  the  lower  limbs. 

On  admission,  there  was  found  a  circumscribed  swelling  over 
the  lower  dorsal  region,  one  of  the  spinous  processes  being 
unusually  prominent,  deflected  about  an  inch  to  the  left  side, 
and  movable,  but  without  crepitus.  Chloroform  was  administered, 
and  traction  made  upon  the  thighs,  with  counter-extension  from 
the  axillae  and  lateral  movement  of  the  pelvis,  first  to  the  left 
and  then  to  the  right  side.  By  this  means  the  line  of  the 
spinous  processes  was  rendered  straight,  and  pads  and  a  bandage 
were  applied  to  keep  it  so.  The  patient  was  then  placed  on  a 
water-bed. 

On  the  following  day,  when  I  first  saw  him,  the  man  com- 
plained of  pain  in  the  lower  part  of  the  back  and  abdomen,  and 
in  the  upper  part  of  the  front  of  the  thighs.  No  pain  resulted 
from  vertical  jarring  of  the  spine.  Owing  to  the  bandages,  the 
spine  itself  was  inaccessible.  The  lower  limbs  were  completely 
paralysed,  but  the  muscles  of  the  abdomen,  thorax,  and  upper 
limbs  had  escaped.  The  plantar  and  cremasteric  reflexes  and 
the  knee-jerk  were  absent. 

Anaesthesia  extended  over  the  front  of  the  lower  limbs  to  as 
high  as  a  point  two  inches  above  the  knee-joint,  the  boundary- 
line  being  concave  downwards,  and  lower  on  the  inner  than 
on  the    outer   sides    of  the  knees,   as   in  the  annexed  diagram. 


132 


SURGERY    OF    THE   SPINAL    CORD. 


Fio.  28. — Anterior 
aspect  of  riffht 
knee  of  J.  M., 
showing  boun- 
dary of  anses- 
thesia. 


In  front  of  the  thighs  there  was  some  hyperalgesia.  From  the 
wish  not  to  disturb  the  patient,  to  whom  the  slightest  move- 
ment caused  great  pain,  the  posterior  aspects  of 
the  lower  limbs  were  not  examined. 

The  urine  was  retained,  had  a  specific  gravity 
of  1026,  and  was  faintly  acid,  containing  no  de- 
posit, but  a  mucous  cloud,  and  traces  of  albumen, 
but  no  sugar.  The  penis  was  not  turgid.  The 
axillary  temperature  was  99°,  and  remained  near 
the  normal  throughout  the  progress  of  the  case. 

During  the  next  few  days  the  hypersesthesia  of 
the  front  of  the  thighs  disappeared.  Faeces  were 
passed  involuntarily  and  unconsciously.  The 
muscles  of  the  lower  limbs  became  very  tense, 
and  vague  sensibility  was  elicited  by  deep  pressure 
on  the  legs.  On  the  fourth  day  a  small  bulla 
formed  on  the  right  heel.  On  the  sixth,  the  urine 
became  ammoniacal  and  purulent,  and  on  the 
eighth  incontinence  ensued.  That  the  latter  was  not  due  to 
retention  only  was  shown  by  the  absence  of  defined  bladder  dul- 
ness,  and  by  the  fact  that  dribbling  continued  even  immediately 
after  the  use  of  the  catheter. 

By  the  twelfth  day  returning  sensation  had  extended  down- 
wards to  below  the  patella  in  front  of  the  lower  limbs,  but  the 
entire  posterior  surfaces  of  both  thighs  as  well  as  of  the  legs 
were  now  found  to  be  anaesthetic.  The  bulla  on  the  heel  had 
healed  up  again. 

On  April  i  5 — i.e.,  thirty-seven  days  after  the  accident — the 
condition  was  as  follows : — The  lower  limbs  were  still  completely 
paralysed  and  a  good  deal  wasted.  Their  muscles  all  presented 
the  partial  reaction  of  degeneration,  giving  no  response  to  the 
faradic  current,  but  reacting  more  readily  to  the  kathodal  than  to 
the  anodal  closing  shock.  The  plantar  reflex  and  knee-jerk  were 
absent,  the  cremasteric  reflex  normal,  and  the  epigastric  very 
lively.  The  limits  of  sensory  affection  were  not  very  well  defined, 
but  there  was  slight  hypersesthesia  and  hyperalgesia,  beginning 
about  one  inch  below  the  umbilicus,  and  extending  to  immediately 
below  the  knees  in  front.  Below  this  area  was  anaesthesia.  Here 
the  limit  was  ^-shaped,  with  the  apex  upwards,  and  reaching 
to  a  little  below  the  patella,  sensibility  extending  about  half  way 
down  the  inner  side  of  each  leg,  and  to  a  much  less  extent 
on  the  outer  side.  Behind  there  was  very  obscure  sensation 
of  the  outer  side  of  the  gluteal  region  and  back  of  the  thighs  and 


J» 

Siin. 

transversely 

,                    i^in. 

,, 

,                    i^in. 

longitudinally 

,                    over  5.Jin 

„ 

,                     over  3in. 

transversely 

,                     over  sjin 

»j 

,                    over  3iu. 

INJURIES    OF   THE    LUMBO-SACKAL   REGION.  1 33 

legs,  but  the  inner  parts  of  the  gluteal  region,  tlie  perineum, 
scrotum,  and  penis,  presented  complete  superficial  anaesthesia. 
Deep  pressure  elicited  vague  sensation  every wli ere.  The  testes 
were  as  sensitive  as  usual.  Observations  with  the  sethesiometer 
yielded  the  following  results  : — 

Anterior  aspect  of  R.  thigh,  twoi^oints  placed  longitudinally  felt  at  a  distance  of  4jin. 
L. 

»  R- 

L. 

Posterior  aspect  of  R. 

L. 

„  R. 

L. 

[The  instrument  would  not  measure  beyond  5^  inches,  and  on  the  backs  of  the 
thighs,  when  placed  transversely,  the  points  could  not  be  separated  more  than 
three  inches  without  passing  beyond  the  confines  of  the  sciatic  nerve  to  those  of 
the  anterior  crural  and  external  cutaneous,  upon  doing  which  they  were  imme- 
diately distinguished.  Great  pressure  was  required  over  the  backs  of  the  thighs 
to  make  the  instrument  felt  at  all,  and  probably  at  no  distance  could  the  two 
points  have  been  distinguished.] 

We  may  then  sum  up  these  observations  by  saying  that  (i.) 
Absolute  anaesthesia  affected  the  inner  part  of  the  gluteal  region 
and  postei'o-internal  aspect  of  the  thigh,  the  perineum,  penis, 
and  scrotum,  and  the  lower  branches  of  the  sciatic  nerve,  as  in- 
dicated by  the  heavy  shading  in  the  annexed  diagrams  (figs. 
29  and  30)  ;  (2.)  Somewhat  less  insensitive  was  the  remainder 
of  the  region  supplied  by  the  large  and  small  sciatic  nerves ;  and 
(3.)  Sensation  was  still  more  perfect  in  the  distribution  of  the 
obturator,  the  anterior  crural,  with  its  long  saphenous  branch, 
and  the  external  cutaneous  nerve ;  but  (4.)  At  an  earlier  period 
(that  indicated  in  fig.  28)  the  plexus  patellae  of  the  obturator 
nerve  was  anaesthetic. 

At  this  same  period  also  we  found  the  skin  of  the  lower  limbs 
rough  and  dry,  yielding,  on  slight  scratching,  a  well-marked  hyper- 
aemic  line.  About  a  fortnight  previous  to  this  date  the  patient 
said  he  had  had  an  erection,  and  possibly  he  might  have  had 
a  second,  but  there  had  been  no  sexual  desire.  His  bladder 
was  beginning  to  regain  retentive  power,  and  he  could  hold  his 
urine  for  some  two  hours  at  a  time,  then  passing  it  involuntarily, 
but  not  unconsciously.  The  fseces  were  still  passed  involuntarily 
and  unconsciously.  There  was  no  affection  of  the  optic  discs.  The 
back  presented  no  pain  or  tenderness,  the  spinous  processes  were 
not  displaced  laterally,  but  that  of  the  first  lumbar  vertebra  was 
markedly  prominent  posteriorly,  there  being  depression  of  those 
above  it. 


134 


SURGERY    OF   THE    SPINAL    CORD. 


About  May  8  the  patient  began  to  suffer  occasionally  from 
a  sensation  of  cramps  (unaccompanied  by  movement)  and  from 
shooting  pains  in  the  lower  limbs  ;  and  about  May  26  he  ac- 
quired slight  power  of  voluntarily  contracting  the  anterior  thigh- 
muscles.  The  cystitis  gradually  improved,  and  the  general  health 
remained  good. 

From  this  time  there  was  practically  no  improvement  beyond 
a  very  slight  gain  in  cutaneous  sensibility,  appreciable  only  by 
measurements  with  the  sesthesiometer,  and  it  was  now  decided 


Fig.  29. 


Fig.  30. 


to  trephine  the  spine,  an  operation  which  was  performed  by  Mr. 
Jones  on  July  14,  1888,  eighteen  weeks  after  the  injury. 

The  patient  having  been  chloroformed,  was  turned  upon  his 
face,  and  an  incision  was  made,  some  five  inches  in  length,  to  the 
left  side  of  the  spine,  and  with  its  centre  opposite  the  projecting 
spinous  process  of  the  first  lumbar  vertebra.  From  both  ends  of 
this,  other  incisions  were  carried  at  right  angles  across  the  spine, 
and  a  rectangular  flap  of  skin  and  subcutaneous  tissue  was  thus 
raised.  By  means  of  the  knife  the  vertebral  muscles  were  cleared 
and  then  held  aside,  exposing  the  arch  of  the  first  lumbar  verte- 


INJURIES    OF   THE    LUMBO-SACRAL    KEGION.  J  35 

bra,  which  was  removed  with  bone-forceps,  so  as  to  lay  bare  the 
dura  mater.  The  latter  appeared  to  be  healthy,  although  pro- 
truding somewhat  backwards,  but  between  the  arches  of  the  first 
lumbar  and  last  dorsal  vertebrae  it  was  compressed  by  a  mass  of 
soft  cicatricial  tissue.  As  much  as  possible  of  this  tissue  was 
removed,  together  with  the  whole  of  the  arch  of  the  last  dorsal 
vertebra,  and  the  theca  was  then  found  to  be  so  much  flattened 
that  its  contents  appeared  to  have  been  quite  cut  across.  Im- 
mediately above  this  region  the  dura  mater  bulged  slightly,  and 
a  small  spicule  of  bone  having  penetrated  it,  some  cerebro-spinal 
fluid  escaped.  All  pressure  on  the  theca  being  now  removed, 
the  skin  flap  was  replaced  and  sutured,  a  drainage  tube  having 
been  first  inserted  in  the  deepest  part  of  the  wound.  The  sur- 
faces were  dusted  with  powdered  boracic  acid,  and  dressed 
with  iodoform  and  sublimated  wood-wool  pads.  No  spray  was 
used. 

On  the  day  after  the  operation  the  temperature  rose  to  1 00°, 
and  there  was  a  good  deal  of  shock,  with  much  pain  in  the 
back.  These  symptoms,  however,  passed  off"  in  a  few  days,  no 
accident  supervening,  and  the  pain  soon  subsiding.  On  the 
fourteenth  day  the  wound  was  healed. 

Although  the  general  health  continued  good,  there  was  unfor- 
tunately no  marked  improvement  after  the  operation.  The  ante- 
rior thigh-muscles  appeared  to  gain  a  little  in  power,  and  the 
anaesthesia  of  the  lower  limbs  diminished  to  some  extent,  but 
these  changes  were  only  very  slow  and  very  slight.  On  October 
10  the  patient  was  sent  to  the  Convalescent  Hospital  at  Cheadle, 
where  he  remained  for  some  time  longer,  but  whence  he  was 
finally  discharged  without  marked  relief 

A  point  of  some  importance  in  the  above  case  is  the  limit  of 
the  anaesthesia  on  the  front  of  the  limb  at  an  early  period,  as 
shown  in  fig.  28.  It  indicates  that,  of  the  region  already  de- 
scribed as  being  supplied  by  the  anterior  ci'ural  and  obturator 
nerves  (third  and  fourth  lumbar  roots),  the  lower  portion  is  sup- 
plied from  the  lower  root. 

Finally,  the  two  following  records,  although  of  old  date,  de- 
scribe tolerably  clearly  the  results  of  an  injury  affecting  chiefly 
the  lower  roots  of  the  sciatic  trunk. 


136  SURGERY    OF   THE   SPINAL    CORD. 

Case  46. — Fracture  of  first  lumhar  vertebra — Paralysis  and 
ancesthesia  involving  second  sacral  roots. 

Cruveilhier  ^  mentions  the  case  of  a  woman,  aged  thirty-five, 
who,  having  sustained  a  fall  of  twelve  feet,  was  rendered  unable 
to  walk,  in  which  condition  she  was  seen  at  the  SaljDetriere  three 
months  later.  She  had  then  "  incomplete  power  "  in  the  muscles 
of  her  legs  and  thighs,  with  involuntary  defgecation  and  micturition. 
Sensation  was  lost  in  the  feet  as  high  as  the  malleoli,  and  was 
obtuse  above  this  point,  but  improved  higher  up  the  limb.  The 
toes  were  strongly  flexed  on  the  metatarsi,  and  the  feet  extended 
on  the  legs.  At  the  autopsy  was  found  a  crush  of  the  first 
lumbar  vertebra,  with  a  bony  projection  about  its  centre  com- 
pressing the  spinal  cord,  which  was  pale  and  degenerated.  The 
Cauda  equina  had  escaped  injury. 

Here  the  paralysis  appears  to  have  chiefly  affected  the  exten- 
sors of  the  ankle  and  toes,  the  posterior  leg-muscles,  by  their 
uncontrolled  contraction,  giving  rise  to  the  deformity :  at  the 
same  time  there  was  anaesthesia  in  the  region  which  previous 
cases  have  led  us  to  regard  as  that  of  the  distribution  of  the 
second  sacral  nerve-roots. 


Case  47. — Fracture  of  first  lumhar  vertebra — Paraplegia — 
Anaesthesia  involving  second  sacral  roots. 

Holthouse "  mentions  a  woman,  aged  forty-two,  who  dropped 
from  the  height  of  a  third-floor  window  on  to  her  feet.  Com- 
plete paralysis  of  the  lower  limbs  and  retention  of  urine  and 
faeces  followed  immediately.  On  the  third  day  (before  which 
no  examination  appears  to  have  been  made)  she  was  found  to 
have  no  sensation  or  reflex  in  the  soles  of  the  feet ;  micturition 
and  defsecation  were  involuntary.  On  the  sixth  day  is  the  some- 
what more  complete  record  that  she  had  no  sensation  in  the 
soles,  but  that  there  was  some  feeling  in  the  calves,  "  and  in  the 
whole  of  the  [?  other  parts  of  the]  limb  on  the  right  side,  but  not 
on  the  left."  Three  days  later  she  was  said  to  have  ana3sthesia 
below  the  ankles.  There  ensued  a  bed-sore  on  the  sacrum, 
cystitis,  and  erysipelas,  and  the  patient  died  on  the  nineteenth  day. 
At  the  autopsy  was  found  a  crush  of  the  first  lumbar  vertebra, 

^  Anatomic  Pathologique,  tom.  ii.,  Maladies  de  la  Moelle,  p.  5. 
*  Lancet,  1858,  vol.  ii.  p.  629. 


INJURIES    OF   THE    LUMBO-SACllAL   REGION.  I37 

fragments  of  the  body  of  which  had  been  driven  backwards, 
"  and  had  crushed  that  part  of  the  spinal  cord  just  above  the 
Cauda  equina ;  "  there  was  no  effusion  of  blood  or  inflammatory 
deposit. 

In  these  two  last  cases,  which  are  so  closely  similar  in  their 
symptoms,  we  should  expect  to  find  anaesthesia  of  the  "  saddle- 
shaped  "  area,  which  is  supplied  by  the  third  sacral  root ;  but  it 
is  exceedingly  probable,  especially  when  we  consider  the  date  of 
the  observations  and  the  sex  of  the  patients,  that  such  a  condition 
would  pass  unnoted. 

As  a  conclusion  to  the  above  series  of  cases,  I  may  mention 
the  following  example  of  tumour  of  the  cauda  equina,  recently 
admitted  to  Mr.  Jones's  wards  in  the  Manchester  Infirmary  for 
retention  of  urine,  which  illustrates  admirably  some  of  the  above 
localisations,  as  well  as  the  assistance  to  be  obtained  from  the 
same  in  the  diagnosis  of  the  exact  seat  of  spinal  lesions. 


Case  48. — Tumour  of  the  cauda  equina,  involving  successively 
the  various  nerve-roots. 

J.  D.,  aged  thirty-one,  was  admitted  to  Mr.  Jones's  wards  in 
the  Manchester  Infirmary  on  April  15,  1889.  His  family  history 
is  unimportant.  He  has  had  no  previous  illness,  and  presents  no 
indications  of  syphilis  or  alcoholism.  Some  six  years  ago  he 
began  to  suffer  from  pain  in  the  lower  part  of  his  back,  extending 
thence  down  the  back  of  the  lower  limbs  to  the  heels ;  at  the 
same  time  he  had  difficulty  in  micturition,  which,  after  about 
three  months,  was  followed  by  complete  retention  of  urine  for  a 
week.  The  latter  condition  improved  a  little,  and  for  about  a  year 
he  was  able  to  pass  urine,  but  at  the  end  of  that  time  he  again 
had  absolute  retention  for  about  three  weeks.  Coincidently  with 
these  troubles  he  began  to  suffer  from  obstinate  constipation. 

This  condition  of  constipation,  difiiculty,  and  occasional  failure 
in  micturition,  with  pain  in  the  back  of  the  lower  limbs,  continued 
until  about  eight  months  ago.  We  may  call  this  the  first  stage 
of  his  illness. 

Eight  months  before  admission  the  pain  in  the  back  of  the 
limbs  disappeared,  and  was  gradually  replaced  by  "  numbness  ;  " 
at  the  same  time  pain  also  began  to  be  felt  in  the  front  of  the 
thighs,  from  the  hips  to  the  knees,  but  no  lower,  and  this  pain  has 
since  continued.      Alongf   with   this  he   has  had  marked   feeble- 


130  SURGERY    OF    THE    SPINAL   CORD. 

ness  in  the  lower  limbs,  especially  below  the  knees,  and  on  the 
right  side.  From  the  eighth  to  the  third  month  before  admission 
he  was  unable  to  have  connection  with  his  wife,  but  had  nocturnal 
emissions  and  erections.  The  bladder  and  rectal  troubles  con- 
tinued.     This  constitutes  the  second  stage  of  the  disease. 

Three  months  ago  the  pain  in  the  front  of  the  thighs,  the 
numbness  of  the  back  of  the  limbs,  and  the  muscular  weakness 
became  markedly  worse,  and  he  ceased  to  have  any  erections. 
Thus  we  reach  a  third  stage. 

At  the  present  time  the  lower  limbs  are  a  good  deal  wasted ; 
they  present  no  paralysis,  but  all  the  muscles  are  weak,  and 
the  toes  show  a  tendency  to  drop  in  walking;  muscular  sense  is 
retained.  The  electric  reactions  are  normal.  The  bowels  are 
very  constipated,  and  the  urine  is  absolutely  retained,  the  catheter 
being  constantly  required. 

Over  the  lower  lumbar  vertebrae,  in  the  middle  line,  there  is  a 
region  which  is  painful  on  pressure  or  movement.  Pain  affects 
the  front  of  the  thighs  in  a  region  corresponding  to  the  dotted 
area  in  the  diagram  (fig.  3  i ),  but  there  does  not  appear  to  be  any 
exaggeration  of  sensibility  to  pain  or  touch.  Anaesthesia  is  no- 
where absolute,  but  there  is  very  great  blunting  of  sensation  in 
the  penis,  scrotum  (except  at  the  upper  part),  perineum,  gluteal 
region,  and  intero-posterior  aspects  of  the  upper  parts  of  the 
thighs,  this  dulness  of  sensation  extending,  although  in  a  less 
marked  degree,  down  the  centre  of  the  backs  of  the  thighs,  over 
the  calves,  except  on  the  inner  side,  and  to  the  soles  of  the  feet, 
where  it  spares  the  great-toe  and  half  the  second  toe.  Still 
slighter  loss  of  sensation  affects  the  front  of  the  knees,  the  outer 
sides  of  the  legs,  and  the  outer  side  of  the  dorsum  of  the  foot. 
In  the  leg  and  foot  the  sensory  deficiency  is  more  marked  on  the 
right  side.  The  testicles  are  not  anaesthetic.  Some  sensation  is 
retained  in  the  urethra,  but  it  appears  to  be  blunted.  The 
annexed  diagrams  (figs.  31  and  32)  represent  these  conditions 
roughly  only,  there  being  actually  much  less  well-defined  limits. 

The  plantar  and  gluteal  reflexes  are  lost  on  both  sides,  the 
cremasteric  is  retained,  the  abdominal  appear  to  be  exaggerated. 
Ankle-clonus  cannot  be  elicited ;  on  the  right  side  there  is  no 
knee-jerk ;  on  the  left  it  was  slightly  marked  on  admission,  but 
disappeared  some  ten  days  later. 

The  general  health  remains  good,  except  for  some  gastric  dis- 
turbance.     The  eyes  are  normal  in  all  respects. 

There  can  be  no  doubt  that  we  have  here  a  pressure  lesion  of 
the  Cauda  equina  ;  the  progress  of  events  is  too  slow  for  us  to  sup- 


INJURIES    OF    THE    LUMBO-SACRAL    REGION. 


139 


pose  that  we  have  an  affection  of  the  spinal  cord  itself;  the  dura- 
tion of  the  case  and  the  course  of  the  symptoms,  to  which  fuller 
reference  will  be  made  immediately,  point  to  a  tumour  rather  than 
to  meningitis  ;  and  the  history  and  appearance  of  the  patient  contra- 
indicate  tubercle,  so  that  the  growth  is  doubtless  a  tumour. 

Taking  this  view,  we  may  thus  explain  the  symptoms,  remem- 
bering always  that,  in  pressure-lesions  of  the  cauda  equina,  the 
lower  roots  almost  invariably  suffer  more  than  those  which  arise 
above  them,  and  suffer  first  from  an  increasing  pressure-lesion. 
In  the  first  stage  we  have   paralysis  of  the   fourth  sacral  root. 


Fig.  31. 


Fig.  32. 


which  supplies  the  bladder  and  rectum,  together  with  irritation, 
causing  pain  in  the  sensory  branches  of  the  first  three  sacral  roots. 
In  the  second  stage,  which  came  on  eight  months  before  admission, 
there  ensued  loss  of  power  of  coitus,  due  to  paralysis  of  the  muscles 
supplied  by  the  third  sacral  root,  and  at  the  same  time  anaesthesia 
supervened  in  the  previously  painful  areas,  and  the  irritation  was 
transferred  to  the  third  and  fourth  lumbar  roots. 

In  the  third  stage,  which  came  on  about  five  months  later,  the 
nervi  erigentes  are  paralysed,  thus  indicating  pressure  on  the 
second  sacral  roots,  anaesthesia  is  well  marked  in  the  cutaneous 
distribution  of  all  the  sacral  roots,  and  is  less  obvious  in  that  of 


I40  SURGERY    OF   THE    SPINAL    CORD. 

the  fifth  lumbar,  and  pain  is  confined  to  the  distribution  of  the 
third  (?  and  fourth)  lumbar  roots.  Motor  weakness  affects  most 
of  these  roots,  but  is  fairly  marked  in  the  second  sacral,  which 
supplies  the  extensors  of  the  toes,  &c.,  and  is  still  greater  in  the 
third  and  fourth  sacral,  which  are  distributed  to  the  bladder, 
rectum,  and  perineal  muscles.  The  two  first  lumbar  roots  en- 
tirely escape. 

If  now  we  inquire  into  the  exact  localisation  of  the  tumour, 
we  must  place  it  below  the  upper  border  of  the  second  lumbar 
vertebra,  because  here  we  have  the  termination  of  the  spinal  cord, 
which,  from  the  nature  and  slow  growth  of  the  symptoms,  is 
probably  not  affected  (c/.  p.  io6).  Again  we  must  admit  that 
the  third  lumbar  roots  are  irritated  by  the  growth,  as  there  is 
pain  in  their  cutaneous  distribution.  Hence  then  we  conclude 
that  it  is  situated  between  the  upper  border  of  the  second  and 
the  lower  border  of  the  third  lumbar  vertebra. 

Lastly,  the  two  following  cases,  although  both  are  non-trau- 
matic, further  illustrate  the  effects  of  a  lesion  implicating  the 
third  sacral  and  subjacent  roots  : — 

A  syphilitic  woman, ^  aged  thirty-two,  suffered  from  absolute 
anaesthesia  of  the  skin  of  the  external  genital  organs,  as  high  as 
the  boundaries  of  the  mons  veneris,  of  the  vaginal  mucous  mem- 
brane, the  perineum,  and  the  inner  aspect  of  the  thighs  in  the 
immediate  neighbourhood  of  the  perineum,  and  over  the  sacrum 
and  gluteal  region,  as  in  Bernhardt's  case.  Together  with  this 
ansesthesia  she  had  paralysis  of  the  bladder  and  rectum,  and  a 
bed-sore  over  the  sacrum,  but  no  further  paralysis  or  sensory 
affection  of  the  limbs.  A  post-mortem  examination  revealed 
gummatous  spinal  meningitis  in  the  sacral  region,  with  "  com- 
pression of  the  roots  of  the  pudendal  plexus"  and  superficial 
caries  of  the  sacrum. 

A  woman,^  aged  thirty-six,  suffered,  as  the  result  of  a  severe 
cold,  from  pains  in  passing  urine,  with  numbness  of  the  nates, 
shortly  followed  by  retention  of  urine  and  faeces,  and,  five  days 
later,  by  involuntary  micturition  and  defaecation.  At  the  end  of 
seven  months  she  presented  ansesthesia  of  the  bladder,  urethra, 
rectum,  perineum,  external  genitals,  vagina,  uterus,  and  lower 
half  of  the  nates,  with  continued  involuntary  micturition  and 
defsecation,  but  with  no  affection  of  sensation  or  movement  in 
the  extremities.  This  condition  was  unchanged  at  the  end  of 
four  years. 

'  Westphal,  Chariti  Annalen,  Jahrgang  I.     Berlin,  1876. 
^  Rosenthal,  Wiener  medizinische  Presse,  1888,  No.  19. 


CHAPTEPt  VI. 

THE    INDICATIONS    FOR     OPERATIVE    TREATMENT 
IN   AFFECTIONS    OF    THE    SPINAL    CORD. 

Omitting  the  suggestions  of  Paulus  -^gineta,  Fabricius  Hildanus, 
and  others,  and  the  case  in  which  Louis  successfully  extracted  the 
fragments  of  a  vertebral  arch  broken  by  a  gunshot  wound,  the 
earliest  recorded  instance  of  a  definite  operation  having  been 
undertaken,  for  the  cure  of  traumatic  compression  of  the  spinal 
cord,  appears  to  have  been  the  case  of  Cline,  who,  at  the  insti- 
gation of  Sir  Astley  Cooper,  performed  this  operation  in  i  8  1 4. 
During  the  last  three-quarters  of  a  century  some  sixty  similar 
operations  have  been  practised,  but  the  results  have  so  far  not 
been  sufficiently  favourable  to  recommend  the  procedure  to  the 
majority  of  surgeons.  The  enormous  impetus  given  to  operative 
surgery  by  the  introduction  of  the  antiseptic  system  and  the  recent 
achievements  of  cerebral  surgery  have,  however,  again  naturally 
raised  the  question  of  the  advisability  of  operating  for  the  relief 
of  injuries  of  the  spinal  cord ;  and  the  brilliant  successes  of  Mac- 
ewen  and  Horsley  have  extended  the  sphere  of  possibly  beneficial 
interference  from  the  traumatic  to  other  compressing  lesions  of  that 
structure.  In  the  following  chapter  I  pi'opose  to  collect  and  to 
criticise  such  evidence  as  we  possess,  bearing  upon  a  question 
which  will  probably  before  long  be  placed  upon  an  entirely  new 
basis.      The  subject  may  conveniently  be  divided  into  sections. 

Section  I. — Traumatic  Lesions. 

Within  the  last  few  years  five  cases  of  spinal  injury  have  been 
trephined  in  the  Manchester  Eoyal  Infirmary,  the  details  of  which 
will  be  found  recorded  in  the  above  pages.  We  may  first  con- 
sider briefly  the  circumstances  connected  with  each  of  these. 

In  Case  9  (p.  20)  there  was  no  question  but  that  the  cord 
was  completely  crushed,  the  condition  of  the  patient  was  un- 
doubtedly hopeless,  and  an  operation  thus  appeared  advisable  as 
allowing  a  possible  chance  of  recovery,  and  as  being  certainly 
incapable  of  rendering  matters  more  serious  than  they  already  were. 
As  a  matter  of  fact,  not  the  slightest  benefit  resulted,  and  the 
post-mortem  examination  showed  that  the  condition  was  not  one 


142  SURGERY    OF    THE    SPINAL    CORD. 

susceptible  of  relief,  inasmuch  as  there  was  no  pressure  upon  the 
cord,  the  bony  displacement  being  very  slight,  and  the  damage 
inflicted  upon  the  nervous  structures  having  doubtless  been  en- 
tirely received  at  the  moment  of  injury,  when  the  cord  had  been 
completely  crushed,  and  had  been  released  only  after  destruction 
of  its  tissue  by  bruising  and  hsemorrhage. 

In  Case  8  (p.  17)  the  symptoms  pointed  to  a  lesion  quite  as 
serious  as  in  the  last  instance,  and  here  also  the  operation  was  a 
last  resort  in  a  desperate  case.  The  result  showed,  however,  that 
the  spinal  cord  was  here  exposed  to  continued  pressure  from  the 
displaced  bones,  and  that  this  pressure  must  have  been  relieved 
by  the  removal  of  the  counter-pressure  due  to  the  excised  arches. 
In  spite  of  this,  not  the  slightest  improvement  resulted  in  the 
symptoms,  and  it  seems  not  improbable  that  the  operation  may 
somewhat  have  shortened  life,  owing  to  further  damage  having 
been  inflicted  upon  the  compressed  cord  by  the  necessary  manipu- 
lations, especially  during  the  period  of  suspended  respiration. 

In  Case  1 1  (p.  26)  the  conditions  were  entirely  different.  The 
course  of  the  case  indicated  clearly  that  the  cord  was  not  entirely 
destroyed,  but  that  at  least  some  of  its  conducting  fibres  main- 
tained their  continuity.  The  spontaneous  improvement,  which  for 
some  time  progressed  very  steadily,  at  first  gave  rise  to  hopes  that 
extensive  regeneration  might  result.  Further,  the  exaggeration  of 
the  plantar  and  patellar  reflexes,  and  the  fact  that  incontinence  of 
urine,  with  an  empty  bladder,  was  present  from  the  commence- 
ment, indicated  at  least  that  the  reflex  centres  had  not  suffered 
from  the  usual  shock,  possibly  that  irritation  rather  than  paralysis 
was  playing  an  important  part  in  the  production  of  the  symptoms. 
When,  therefore,  recovery  had  progressed  for  some  time,  and  had 
then  come  to  a  standstill,  it  appeared  probable  that,  by  trephining, 
it  might  be  possible  to  remove  any  source  of  irritation  as  well  as 
of  compression,  and  that  the  favourable  course  might  thus  be  re- 
established. Without  operation  the  patient's  life  was  certainly 
not  worth  living,  nor  likely  to  be  much  prolonged,  exhausted  as 
he  was  by  pain,  sleeplessness,  and  cystitis.  Further,  the  depres- 
sion of  the  fifth  cervical  spinous  process,  regarded  in  connection 
with  the  upper  limit  of  the  paralysis,  appeared  to  indicate  a  dis- 
location forwards  of  the  fifth  cervical  vertebra  of  the  usual  type, 
giving  rise  to  narrowiug  of  the  medullary  canal  opposite  the  upper 
border  of  the  body  of  the  sixth.  Even  after  the  operation  this 
view  received  countenance  from  the  backward  projection  of  the 
theca  in  this  region. 

The  result  proved  that  there  was  no  persistent  compression 
of  the  cord  ;  that  the  lesion  of  the  vertebral  column  was  prac- 


INDICATIONS    FOR  OPERATIVE    TREATMENT.  1 43 

tically  a  diastasis  only,  and  was  at  a  higher  level  than  had  been 
anticipated ;  that  the  affection  of  the  cord  was  the  result  of  a 
merely  temporary  crush,  with  extravasation  of  blood  ;  and  that 
consequently  an  operation  could  by  no  possibility  have  been  of 
any  service.  The  cause  of  death  was  undoubtedly  a  re-establish- 
ment of  traumatic  myelitis,  as  a  result  of  the  local  interference. 

Case    32  (p.  94)  differed  materially  from  the  last  three,  both 
in  the  nature  of  the  injury  and   in  the  result.      The  injury  did 
not  affect  the  spinal  cord  at  all,  but  was  confined  to  the  cauda 
equina,  and  an  interval  of  four  months  and  a  half  had  elapsed 
between  its  receipt  and  the  date  of  the  operation.      During  the 
earlier  part  of  this  period  the  symptoms  had  improved,  but,  as  in 
the  last  case,  this  improvement  had  ceased,  and  for  some  eight 
weeks  there  had  been  no  change  in  the  patient's  condition.      The 
operation  revealed  a  large  amount  of  cicatricial  tissue  compressing 
the  nerves  of  the  cauda  equina,  and  on  the  removal  of  this  tissue 
improvement  recommenced,  and  was  eventually  very  satisfactory. 
In    Case    45    (p.    1 31)   the    displacement   of   the    spine  was 
at  the  junction   of   the    last   dorsal    and   first   lumbar   vertebrae, 
which  would  probably  correspond  to  the  region  of  exit  from  the 
cord  of  the  fifth  lumbar  nerve-roots.^      Hence  the   crush  would 
affect  the  conus  medullaris  at  this  level,  together  with  the  nerves 
of  the  Cauda  equina,  which  here  accompany  it.      The  functions  of 
the  latter   were  only  partially  destroyed.      After    an  interval  of 
eighteen  weeks,  and  after  such  slight  improvement  as  was  at  first 
manifested   had  entirely   ceased,   the   operation   was   resorted  to. 
As  in  the  last  case,  cicatricial  tissue  was  found  to  be  surrounding 
the  nervous  structures,   and    this   tissue  was    removed ;    besides 
which,  the  cord  itself  appeared  to  be  almost  entirely  torn  across. 
The  subsequent   improvement  was  practically  nil,    except  for  a 
slight   recovery    of  function  in   the   upper  lumbar  roots,   which, 
having  left  the  cord  above  the  seat  of  the  lesion,  form  the  com- 
mencement of  the  cauda  equina. 

The  above  five  cases  constitute  the  whole  of  my  own  experi- 
ence of  the  operation  of  trephining  the  spine,  as  performed  for 
traumatic  lesions,  but  I  have  collected  in  the  Table  which  fol- 
lows all  the  recorded  cases  which  I  can  find.  Excellent  sum- 
maries up  to  date  are  given  by  Gurlt,^  Ashhurst,^  and  Werner,* 
and  these  have  been  freely  used,  being  checked  and  supplemented 
by  reference  to  such  of  the  original  reports  as  are  accessible  to  me. 

^  Gowers,  Diseases  of  the  Nervous  System,  vol.  i.  p.  106. 

-  Ilandhuch  der  Lehre  von  den  Knoche^ibriicken.     Hamburg,  1 864. 

*  Injuries  of  the  Spine.     Philadelphia,  1867. 

*  Die  Trepanation  dcr  Wirbelsdule.     Strassburg,  1879. 


144 


SURGERY    OF    THE    SPINAL   CORD. 


No. 


13 


14 


Operator  and 
Date. 


Cline. 
1814. 


TVickham. 

1819. 

Oldknow. 
1819. 

Attenburrow. 


Tyrrell, 


Rhea  Barton. 
1824. 


Tyrrell. 
1827. 

Alban  Smith. 
1828. 

Holscher. 
1828. 


South. 


Rogers. 
1834. 


Edwards. 


Laugier. 
1840. 


Potter. 
1844  (?). 


Reference. 


South's  Chelius,  London, 
1847.     Vol.  i.  p.  539. 


Tyrrell's  edit,  of 
Cooper's  Lectures  on 
Surgery,  London, 
1825.     Vol.  ii.  p.  20. 

Cooper's  Fractures  and 
Dislocations,  London , 
1822. 

Tyrrell's  edit,  of 
Cooper's  Lectures  on 
Surgery,  London, 
1825.     Vol.  ii.  p.  20. 

Ibid.,  p.  II. 


Cooper's  Fractures  and 
Dislocations,  God- 
man's  American  ed., 
or  Packard's  Mal- 
gaigne. 

Lancet,  1827. 

North  American  Med. 

and  Surg.  Jour.  Vol. 

viii. 
Hannov.  Annal.  f,  d. 

aes.  Hcilk,    Bd.   iv. 

1839. 


South's  Chelius.  Lon- 
don, 1847.  Vol.  i. 
P-  541- 

Amer.  Jour.  Med.  Sc, 
O.  S.     Vol.  xvl. 


Brit.  For.  Med.  Chir. 

Rev.,       1838,  and 

M'Donnell,  Dub. 

Quart.    Jour.  Med. 
Sci.,  1865. 

Lesions  traumcUiques 
de  la  Moelle  6pinire. 
Paris,  1848, 


Hurd,  New  York  Jour. 
Med.,  1845. 


Symptoms  before  Operation. 


Total  motor  and  sensory  par- 
alysis of  the  lower  ex- 
tremities. 


Total  motor  and  sensory  par- 
alysis of  trunk  and  lower 
limbs :  i^artial  of  upper 
limbs. 


Motor  and  sensory  paralysis 
below  Foupart's  ligament : 
involuntary  defiEcation 
and  micturition  :  depres- 
sion of  twelfth  dorsal  ver- 
tebra. 

Total  paralysis  of  trunk  and 
lower  limbs  :  incontinence 
of  urine  and  faeces. 


Total  paralysis  of  lower 
limbs :  last  dorsal  dis- 
located backwards. 

Paralysis  of  all  the  limbs 
except  of  muscles  above 
the  elbow. 

Total  paralysis  of  lower 
limbs  :  obvious  dislocation 
forwards :  on  13th  day 
commencing  gangrene   of 


Paralysis  :  great  dyspnoea : 
depression  of  first  lumbar 
spiue. 


Paralysis    of    lower    limbs, 
bladder,  and  rectum. 


Total  motor  and  sensory 
paralysis  of  lower  limbs : 
retention  of  urine :    bed- 


Motor  and  sensory  paralysis 
below  the  breast :  violent 
pain  in  neck:  bed-sores: 
cystitis.  Previous  lung 
disease. 


Period  of 

Operation 

after  Injury. 


Second 
day. 


Eight  days. 


Six  days. 


Two  days. 


Twelve 
days. 


One  day. 


Two  years. 


Thirteen 
days. 


Two  days. 


"A  con- 
siderable 
time." 


Four  days. 


One  hun- 
dred days. 


INDICATIONS    FOR   OPERATIVE    TREATMENT. 


145 


Nature  of  Opera- 
tion. 


Eemoval  of  two 
isolated  spin- 
ous processes 
and  one  of  the 
arches. 

Removal  of  part 
of  seventh  cer- 
vical vertebra. 

Removal  of 
seventh  cer- 
vical spinous 
process. 


Removal  of 
twelfth  dor- 
sal and  first 
lumbar  arches. 


Removal  of 
seventh  dorsal 
arch. 


Removal    of 

twelfth  dorsal 

arch. 
Removal  of  third 

and        fourtli 

dorsal  spines. 
Removal    of 

eleventh    and 

twelfth  dorsal 

arches. 

Removal  of  an 
arch  which 
was  fractured 
on  one  side. 

Removal  of 
twelfth  dorsal 
and  first  lum- 
bar arches. 


Elevation  of  one 
of  the  lumbar 
arches. 


Removal  of  spine 
of  eighth  and 
arch  of  ninth 
dorsal  verte- 
brae. 

Removal  of  parts 
of  four  lower 
cervical  and 
two  upper  dor- 
sal vertebrae. 


Subsequent  Course. 


No  effect. 


Freer  breathing :   distinct 
return  of  sensation. 


Immediate  return  of  sensa- 
tion on  inner  aspect  of 
thigh :  after  one  day  sen- 
sation down  to  the  toes : 
peritonitis  secondary  to 
bladder  mischief. 

Return  of  sensation  after 
second  day. 


Return  of  sensation  in 
hips.  Death  from  pleu- 
risy. 

Healing  of  a  gluteal  bed- 
sore :  return  of  sensa- 
tion as  far  as  the  thighs. 

Wound  healed  in  six 
weeks.  Return  of  sen- 
siition  in  lower  limbs : 
slight  mobility  of  legs  : 
could  sit  up. 


Relief  of  breathing :  return 
of  sensibility  in  lower 
limbs :  pain  in  feet. 
Gangrene  of  right  foot, 
where  thei'e  was  a  com- 
pound fracture. 

Lived  for  fifteen  years : 
return  of  functions  of 
bladder  and  rectum : 
afterwards  father  of 
children  :  could  never 
walk. 

Slight  relief  of  respira- 
tion in  two  hours : 
jmeumonia,  &c. 


Almost  immediate  return 
of  sensation :  wound  did 
well :  later,  respiratory 
troubles. 


Result. 


Death  on  nine- 
teenth day. 


Death  in  one 
day. 

Death  on  fol- 
lowing day. 

Death. 


Death  on  fif- 
teenth day. 


Death  in  3I 

days. 


Death  in  eight 
days. 

Incomplete 
recovery. 

Death  in  fifteen 
weeks. 


Death  in  ten 
days. 


Incomplete  re- 
covery. 


Death  in  four 
days. 


Death  in  eight- 
een days. 


Region  Affected  and 
Post-mortem  Appearances. 


Fracture  of  twelfth  dor- 
sal, displacement  of 
eleventh :  cord  al- 
most torn  through. 

Fracture  of  seventh  cer- 
vical vertebra. 


Fracture  of  seventh  cer- 
vical :  extensive  ex- 
travasation of  blood. 


Fracture  of  last  dorsal 
and  first  lumbar  verte- 
brae :  exudation  on 
meninges:  cord 
healthy :  cystitis  : 
peritonitis. 

Dislocation  of  seventh 
cervical,  fracture  of 
ninth  dorsal. 


Dislocation  of  twelfth 
dorsal  vertebra. 

Middle  dorsal  spine : 
vertebrae  ankylosed. 

General  oedema :  hydro- 
pericardium  :  connec- 
tive tissue  masses  at 
site  of  operation. 


Fracture  of  first  lumbar 
vertebra :  cord  nor- 
mal. 


Lumbar  region. 


Fracture  of  seventh, 
eighth,  ninth,  and 
tenth  dorsal  vertebrae : 
cord  completely  torn : 
fractured  ribs  :  pneu- 
monia. 

Lower  cervical  and 
upper  dorsal  regions. 


K 


146 


SURGERY    OF   THE   SPINAL    CORD. 


No. 

Operator  and 
Date. 

Reference. 

Symptoms  before  Operation. 

Period  of 
Operation 

after  Injury. 

IS 

Walker. 

Catalogue  of  the  Mu- 

Motor and  sensory  paralysis 

One  day. 

1845. 

seum  of  the  Boston 
Society  for  Medical 
Improvement,  1847. 

below  the   breast:    dysp- 
noea :  retention  of  urine  : 
incontinence     of     faeces : 
priapism. 

16 

Mayer. 

V.  Walther  and  v.  Am- 

Immediately     after     blows 

About  six 

1846. 

mon's  J"oMr.  der  Chir- 
urgie.    Bd.  38. 

from  a  stick,  pain  and  dis- 
tinct  cracking    in    back  : 
two  months  later,  increas- 
ing weakness  in  back  and 
anaesthesia  of  lower  limbs. 
In  five  months  total  motor 
and  sensory  paralysis   of 
trunk    and  lower  limbs : 
incontinence     of     urine : 
diflBcult  respiration :  pain- 
ful crepitus  on  movement. 

months. 

17 

Blair. 

1852. 

Ballingall's  Outlines  of 
Military      Surgery, 
Edinburgh,  1852. 

? 

V 

18 

Blackman. 

American  edit,  of  Vel- 

Complete  motor  and  sensory 

Four  and 

1854. 

peau.    Vol.  ii.  p.  392. 

paralysis  of  lower  limbs  : 
incontinence  of  urine  and 
faeces :      irregularity      of 
upper  part  of  sacrum. 

a  half 
years  (?). 

19 

Blackman. 
1854. 

Hutchison,  Am^r.  Med. 
Times,  1861. 

7 

Five  hours. 

20 

Jones,  G.  M. 

Med.  Times  and   Ga- 

Motor and  sensory  paralysis 

Six  days. 

1856. 

zette,  1856.     Vol.  ii. 
p.  86. 

below     sternum :      arms 
could    only    be     moved 
upwards :     sensation     in 
arms,  but  not  in  fingers : 
excessive   priapism  :    dia- 
phragmatic    respiration : 
retention  of  urine  :  cere- 
bral symptoms. 

21 

Hutchison. 

Amer.     Med.     Times, 

Total  motor  and  sensory  par- 

Ten days. 

1857. 

1861. 

alysis    below    umbilicus : 
no  reflexes  :  priapism  :  re- 
tention followed  by  incon- 
tinence of  urine  :  respira- 
tory troubles :  depression 
of  eighth  and  ninth  dor- 
sal spines  with  crepitus. 

22 

Smith,  Stephen. 

Hutchison,  Am^'.  Med. 

Motor  and  sensory  paral3'sis 

One  day. 

1858. 

Times,  1861. 

below     sixth     intercostal 
nerve  :  numbness  and  for- 
mication in  arms :  reten- 
tion of  urine  :  priapism  : 
bed-sores  on  second  day. 

23 

Potter,  H.  A. 

Amer.  Jour.  Med.  Sc. 

Total  paralysis,  except  that 

A  few  days. 

1859. 

N.  S.    Vol.  xiv. 

the  hands  could  be  slightly 
raised. 

24 

Potter,  H.  A. 
1862. 

Ibid. 

Same  case    as    last.      Con- 
tinued paralysis :  general 
condition  good. 

Three  years. 

INDICATIONS   FOR    OPERATIVE   TREATMENT. 


147 


Nature  of  Opera- 
tion. 


Removal  of  sixth 
cervical  spin- 
ous process, 
which  was 
broken  but 
not  depressed. 


Resection  of 
seventh  dorsal 
arch,  which 
was  obviously 
compressing 
the  cord. 


Removal  of  i| 
ins,  of  upper 
part  of  sacrum, 
which  was  de- 
pressed. 


Resection  of 
third  and 
fourth  dorsal 
arches :  no  in- 
jury found  : 
then  resection 
of  fifth  and 
sixth  cervical 
arches. 

Removal  of 
eighth  and 
ninth  dorsal 
spines  and 
tenth  dorsal 
arch:  cord 
laid  bare  for 
2J  ins. 

Resection  of  de- 
pressed arch 
of  tenth  dorsal 
vertebra. 


Resection  of  fifth 
and  sixth  cer- 
vical arches : 
cord  pulsated. 


Resection  of 
fourth,  sixth 
(?),  and  se- 
venth cervical 
arches. 


Subsequent  Course. 


Return  of  sensation  in 
three  days,  complete  in 
two  and  a  half  months : 
later  control  over  blad- 
der and  rectum :  mus- 
cular tremors,  contrac- 
tures :  slight  atrophy : 
slight  power  in  lower 
limbs. 

Return  of  voluntary  mic- 
turition. For  nine  days 
restoration  of  sensation 
in  lower  limbs  with 
hyperaesthesia  and  tre- 
mors, but  no  motor 
power :  then  exhaus- 
tion, fever,  and  bed- 
sores. 


' '  A  successful  result." 


After  some  hours,  con- 
sciousness of  micturi- 
tion, and  a  day  later  of 
defsecation  :  gradual  re- 
turn of  sensation,  and, 
after  five  weeks,  of 
voluntary  power  in  legs. 


Return  of  sensation  as  far 
as  umbilicus,  and  freer 
movement  of  arms  on 
same  day :  return  of 
bladder  sensation :  sud- 
den death. 


No  improvement :  respir- 
atory failure :  wound 
gangrenous. 


No  improvement. 


Wound  healed  in  three 
months :  could  sit  and 
move  head  :  left  hand 
freer  mobility  :  spastic 
symptoms  in  lower 
limbs. 

No  effect. 


Result. 


Incomplete  re- 
covery. 


Death  in 

twenty-one 

days. 


Incomplete  re- 
covery. 


Death  in  eight 

days. 
Death  on  fifth 

day. 


Death  on 
twentieth  day. 


Death  soon 
after  the 
operation. 


Incomplete 
recovery. 


Unrelieved. 


Region  AflFected  and 
Post-mortem  Appearances. 


Sixth  cervicaL 


Compression  and  de- 
generation of  cord 
opposite  seventh  dor- 
sal :  impacted  fracture 
of  this  vertebra  with- 
out callus :  fracture 
of  several  spinous  pro- 
cesses :  abscess  in  an- 
terior mediastinum. 


Sacrum. 


Fracture  of  upper  dor- 
sal spine. 

Fracture  of  bodies  of 
fifth  and  sixth  cervi- 
cal vertebrae :  extra- 
vasation in  and  around 
cord :  tearing  of 
nerve-roots. 


Fracture  of  several  dor- 
sal spinous  processes, 
three  bodies  and  two 
ribs :  cord  torn  :  pyo- 
pneumothorax. 


Fracture  of  tenth 
dorsal :  no  disloca- 
tion :  extravasation  of 
blood  from  cervical 
vertebrae  to  sacrum. 

Fracture  of  sixth  cer- 
vical spinous  pro- 
cess :  dislocation  : 
arch  of  fifth  almost 
divided  cord. 

Cord  not  united  :  theca 
thiuned. 


148 


SURGERY   OF   THE    SPINAL   CORD. 


No. 


25 


26 


27 


[Operator  and 
Date. 


Potter,  H.  A. 
i86o(?). 


M'Donnell. 

1865. 


Gordon, 

1865. 


28 


29 


32 


Willett. 
1865. 

Tillaux. 

1865. 


Tvrrell. 

1866. 
Maunder. 

1866. 


Clieever. 
1867. 


Reference. 


Amer.  Jour.  Med.  Sc. 
N.  S.     Vol.  xiv. 


Dublin  Jour.  Med.  Sc. 
Vol.  xl. 


Dub,  Journ.  Med.  Sci. 
Vol.  xlii. 


Lancet,  1866.    Vol.  i. 


Bull.  (j6n,  de  TMrap. 
m6d.  et  chir.,  1866, 
p.  202. 


Dub.  Jourv.  Med.  Sci. 

Vol.  xlii. 
Lancet,  1867.     Vol.  i. 


Fir.'<t  Med.  and  Snr<i. 
Jtep.  of  the  Boston 
dtp  Hospital,  ]  Jos- 
ton,  1870,  p.  577. 


Period  of 
Symptoms  before  Operation.         Operation 
after  Injury. 


Paralysis  of  lower  limbs, 
bladder,  and  rectum : 
ansesthesia  of  soles  of 
feet :  loss  of  reflexes  :  bed- 
sores :  prominence  of  first 
and  depression  of  second 
lumbar  spine. 


Paralysis  of  lower  limbs, 
bladder,  and  rectum : 
bed-sores.  At  end  of  eight 
weeks  total  paralysis  of 
lower  limbs  except  thigh, 
which  was  paretic  only  : 
sartorius  not  affected : 
ansesthesia  in  feet :  above 
this  numbness :  hyper- 
esthesia of  right  thigh  : 
no  reflexes  below  knee. 

Complete  motor  and  sensory 
paralysis  of  all  limbs  and 
trunk :  threatened  as- 
phyxia on  second  day. 

Total  motor  and  sensory 
paralysis  of  lower  limbs  : 
no  reflexes :  retention  of 
urine  and  fjeces :  semi- 
erection  :  difficulty  of 
breathing :  bed-sores  :  de- 
pression of  first  lumbar 
spinous  process. 


Motor  and  sensory  paralysis 
(not  quite  complete)  be- 
low nipples :  diaphragma- 
tic respiration :  retention 
of  urine  and  faeces  fol- 
lowed by  incontinence : 
prominence  of  seventh  cer- 
vical spine. 

Paralysis  of  motion  and  sen- 
.sation  in  lower  limbs : 
priapism :  dyspnoea  : 

coma :  crepitus  at  fifth 
and  sixth  dorsal  vertebra* : 
emphysema :  probably 
fi-actured  ribs. 


Thirty- 
seven  days. 


Sixty-eight 
days. 


Two  days. 


Nine  days. 


Two  days. 

Twenty- 
two  days. 


Tliree 
liours. 


INDICATIONS  FOR    OPERATIVE  TREATMENT. 


149 


Nature  of  Opera- 
tion. 


Resection  of  fifth, 
sixth,  and  se- 
venth cervical 
arches :  dis- 
tinct pulsation 
of  cord. 

Resection  of  last 
dorsal  (?)  arch: 
dura  unopened. 


Resection  of  first 
lumbar  or 
twelfth  dorsal 
arch :  dura 
not  opened. 


Not  completed. 


Removal  of  first 
lumbar  spin- 
ous process, 
which  was 
broken  off 
and  displaced: 
dura  not  com- 
pressed. 


Resection  of  first 
and  second 
dorsal  arches. 


Removal  of  com- 
minuted spin- 
ous processes 
of  second, 
third,  fourth, 
and  fifth  dor- 
sal vertebrae, 
and  third  and 
fourth  laminae. 


Subsequent  Course. 


On  first  day  return  of  sen- 
sation in  soles,  and  of 
power  in  tliighs :  fourth 
day,  sensation  normal : 
seventh  day,  return  of 
reflexes :  improvement 
in  bed-sores  and  uiine  : 
some  power  over  blad- 
der :  marked  power  in 
thighs,  none  below 
knees :  then  rigors,  diar- 
rhoea, sudden  death. 

Urine  acid  after  fourth 
day :  on  twenty-sixth 
day  normal  micturition : 
in  eight  weeks  return  of 
sensation  and  partially 
of  motion  in  lower 
limbs:  bed-sores  healed: 
in  six  months  could  sit 
up  easily;  still  had  in- 
voluntary defaecation : 
exfoliation  of  a  splinter 
of  bone. 


Rigors,     delirium,      &c. : 
'  paralysis    extended    to 
clavicles. 


Wound  doing  well  for  first 

three  weeks. 
Relief    of    dyspnoea    and 

cough,    and    of    pain : 

death  from  respiratory 

troubles. 


"Respiration  modified  by 
operation. " 


Result. 


Death  in  four 
days. 


Death  on  seven- 
teenth day. 


Incomplete  re- 
covery. 


Death  during 
operation. 


Death  in  eleren 
hours. 


Death  on  13th 
day. 


D  e  ath  in 
twenty-four 
hours. 


Region  Affected  and 
Post-mortem  Appearances. 


Cord  not  torn  :  large  ex- 
travasation about  for- 
amen magnum  :  frac- 
ture of  occipital  and 
left  parietal  bones. 

Fracture  of  first  lumbar 
vertebra :  dislocation 
forwards  of  twelfth 
dorsal :  cord  compres- 
sed but  not  inflamed : 
cystitis,  pyelo-ne- 
phritis,  &c. 


Fracture  of  twelfth  dor- 
sal or  first  lumbar. 


Dislocation  of  fifth  cer- 
vical :  extravasation 
of  blood. 

Transverse  fracture  of 
first  lumbar  without 
displacement :  dura 
uninjured  :  cord  not 
torn,  but  contained 
effusion  of  blood  and 
showed  ascending 
myelitis :  haemor- 
rhage in  vertebral 
canal,  but  no  com- 
pression :  fracture  of 
eighth  and  ninth  ribs. 

Injury  of  lower  part  of 
vertebral  column. 

Seventh  cervical  par- 
tially dislocated  for- 
wards :  cord  softened : 
pyaemia. 


Upper  dorsal. 


150 


SURGERY   OF   THE   SPINAL   CORD. 


No. 


33 


34 

35 
36 

37 
38 

39 

40 

41 
42 

43 

44 


4S 


Operator  and 
Date. 


Cheever. 
18—, 


Willard. 
1871. 


Nunneley. 


Nnnneley. 

18—. 
Nunneley. 

18—. 


Nunneley. 
18-. 


Stamen. 
18—. 


Stem  en. 

18—. 
Stemen. 

18—. 
Maydl. 

188-. 


Liicke. 
1877. 


Macewen. 
1885. 


Reference. 


First  Med.  and  Surg. 
Rep.  of  the  Boston 
City  Hospital,  Bos- 
ton, 1870,  p.  577. 


Amer.  Jour.  Med.  Sc. 
Vol.  Ixiii.,  April 
1872.  {Chicago  Med. 
£!xaininer,Oct.  1871.) 

St.  Bartholomew's  Hos- 
pital Rep.    Vol.  vi. 

Med.  Times  and  Ga- 
zette, August  1869. 

Ibid. 

Ibid. 


Ibid. 


Fort  Wayne  Joum. 
Med.  Sci.  1883 
(Lidell,  Ashhurst's 
System  of  Surgery). 

Ibid. 

Ibid. 

Albeit,  Lehrbuch  der 
Chirurgie,  Vienna, 
1884.     Vol.  ii.  p.  55. 

Werner,  Die  Trepana- 
tion der  Wirbelsdule, 
Strassburg,  1879. 


Brit.  Med.  Jour.,  1888. 
Vol.  ii.  p.  308,  Case 


Symptoms  before  Operation. 


Complete  paralysis  below 
nipples :  partial  in  upper 
limbs  :  abdominal  respira- 
tion :  depression  opposite 
sixth  cervical  vertebra : 
retention  of  urine  :  tym- 
panites :  high  fever. 

Motor  and  sensory  paralysis 
of  lower  limbs :  retention 
of  urine. 

A  man  aged  30. 


Complete  motor  and  sensory 
paralysis  of  twelfth  dorsal 
and  subjacent  nerves  :  re- 
tention of  urine  and  fasces  : 
tympanites :  cremasteric 
reflex  present,  plantar 
slightly  marked :  de- 
pression of  eleventh  dorsal 
spine :  crepitus. 


"Absolute  motor  paralysis 
[of  lower  limbs],  with  in- 
continence : "  hyperaesthe- 
sia :  wasting  of  limbs : 
loss  of  electric  reactions : 
bed-sores  :  cystitis  :  fever. 


Period  of 

Operation 

after  Injury. 


Twenty- 
four  hours. 


A  few 
hours  (?), 


Ten  days. 


Five  weeks. 


Thirty-six 
liours. 


Six  weeks 


TNDICATIOlSrS    FOR   OPERATIVE   TREATMENT. 


'51 


Nature  of  Opera- 
tion. 


llemoval  of 
sixth  and  part 
of  fifth  cer- 
vical arches. 


Removal  of 
second  lumbar 
arch,  which 
was  fractured. 


in 


Resection  of  two 
vertebral 
arches  in  dor- 
sal region. 

Removal  of  com- 
minuted frag- 
ments of  bone 
pressing  on  the 
cord,  and'  re- 
section of  en- 
tire arch  and 
left  transverse 
process  (of 
eleventh  dor- 
sal) :  cord 
was  somewhat 
flattened :  ex- 
tension gave 
more  space : 
wound  su- 
tured except 
in  centre : 
"Listerian 
dressing. " 

Removal  of  frac- 
tured twelfth 
dorsal  arch, 
and  dense  con- 
nective tissue 
on  posterior 
aspect  of  dura. 


Subsequent  Course. 


No  improvement ; 
pyrexia  (iio°). 


hyper- 


Apparently  no  change. 


Excellent  health  for  2^ 
years  after,  but  leg  re- 
mained partially  para- 
lysed. 


'  The   patient    recovered 
from  the  operation. " 


Several  times  during  oper- 
ation slight  pressure  on 
cord  caused  movements 
of  lower  limbs  (in  spite 
of  deep  chloroform  nar- 
cosis): partial  recovery 
of  sensation  in  three- 
quarters  of  an  hour,  im- 
proved by  extension : 
hence  extension  by 
weight  of  about  six 
pounds  to  each  leg : 
movements  of  toes  on 
eighth  day  :  pleurisy  : 
cystitis  :  bed-sores  :  ex- 
foliation of  a  small  se- 
questrum :  finally 
woundhealed:  complete 
anaesthesia  and  para- 
lysis: bed-sores:  incon- 
tinence of  urine,  &c. 

Same  night  limbs  warmer: 
third  day,  toes  mov- 
able :  after  a  month 
tenotomy  for  contrac- 
tures :  then  rapid  gain 
of  power :  in  three  years 
could ' '  move  about  with 
ease,  but  with  a  para- 
plegic  gait."  


Result. 


Death  in  nine 
hours. 


Death  on  tenth 
day. 

Death. 
Death. 


Death. 
Death. 


Partial  re- 
covery. 

Relieved. 


Not  benefited. 
Death. 


Not  benefited. 


Partial  re- 
covery. 


Region  Affected  and 
Post-mortem  Appearances. 


Forwards  dislocation  of 
sixth  cervical. 


Second  lumbar. 


"  Injuries  such  as  not  to 
allow  of  recovery  tak- 
ing place." 
Do. 

Do. 
[Nunneley's  cases  are  all 
very    briefly  referred 
to  by  himself.] 


Dislocation  in  dorsal 
region :  cord  was 
crushed. 

Probably  dislocation 
and  fracture  of 
eleventh  dorsal :  cord 
compressed. 

[Slight  improvement  at 
first,  from  relief  of 
pressure :  then  appa- 
rently myelitis.] 


Fracture  of  twelfth  dor- 
sal vertebra. 


152 


SUKGERY    OF   THE   SPINAL   CORD. 


No. 

Operator  and 
Date. 

Lauenstein. 

Reference. 

Symptoms  before  Operation. 

Period  of 
Operation 

46 

after  Injury. 

Centralblatt  fur  Chir- 

Could  not  stand,  but  moved 

Ten  weeks. 

1886. 

urgie,  1886.    No.  51, 
p.  888. 

legs  in  bed  :  limbs  wasted 
and  cold  :  reflexes  slight : 
no  anaesthesia:   unconsci- 
ous defsecation  :  retention 
and    overflow    of    urine : 
cystitis  :  failure  of  plaster 
jacket :   subsequent  fever 
and    general     marasmus, 
with  some  anaesthesia  of 
right  thigh  :  angular  cur- 
vature. 

47 

Keetley. 

Brit.  Med.  Jour.,  1888. 

]\Iotor  and  sensory  paralysis 

Three 

1888. 

Vol.  ii.  p.  421. 

below  fifth  cervical  nerve  : 
priapism :    depression    at 
back  of  neck. 

hours. 

48 

Horsley. 

Med.      Chir.      Trans. 

Absolute  motor  and  sensory 

A  few  days 

1887. 

Vol.  Ixxi.,  i888,  p. 
400. 

paralysis  of  lower  limbs  : 
loss  of  control  over  blad- 
der and  rectum :  cystitis  : 
severe    bed-sore :    promi- 
nence of  eleventh  dorsal 
spine. 

(?)• 

49 

Horsley. 

Ibid. 

"A  fracture." 

9 

5° 

Duncan. 

Edin.      Med.      Jour., 

Complete  loss  of  motion  and 

A  few 

1888. 

March  1889,  p.  830. 

sensation  from  the  groin 
downwards :   retention  of 
urine  :  projection  and  mo- 
bility of  eleventh  dorsal 

hours  (?). 

SI 

Duncan. 

1889. 

HM.,  p.  831. 

spine. 
"Complete  paraplegia:"  re- 
tention of  urine :   projec- 
tion of  third  lumbar  ver- 
tebra :  extreme  collapse. 

One  day. 

INDICATIONS    FOR   OPERATIVE   TREATMENT. 


153 


Nature  of  Opera- 
tion. 


Removal    of 

twelfth  dorsal 
and  fii-st  lum- 
bar arches — 
the  former 
comminuted— 
and  of  thicken- 
ed dura :  care- 
ful antiseptic 
precautions. 


Removal  of  fifth 
and  fourth  cer- 
vical arches  : 
membranes  ex- 
posed, free 
from  tension, 
unusually  soft. 

Removal  of 
eleventh  dor- 
sal  spine, 
which  was  de- 
pressed, and  of 
tenth  dorsal 
arch :  dura 
healthy :  not 
opened,  but 
accidentally 
punctured. 


Removal  of  tenth , 
eleventh,  and 
twelfth  dorsal 
arches  :  dura 
not  opened. 

Removal  of 
arches  of  se- 
cond and  tliird 
lumbar :  body 
of  former  dis- 
placed about 
I  in.  forwards : 
membranes 
blue  and  dis- 
tended :  dura 
opened,  giving 
exit  to  blood 
and  clots: 
Cauda  not 
much  affected: 
wound  in  dura 
closed:  dis- 
placement of 
bones  reduced, 
and  reduction 
maintained  by 
pads  and  plas- 
ter jacket. 


Subsequent  Course. 


Cord  touched  during 
operation,  causing  con- 
traction in  limb  :  to  this 
is  attributed  temporary 
total  paralysis  in  pe- 
ronei :  shortly  severe 
jjaiu  in  back  and  limbs  : 
wound  healed  on  fourth 
day  :  fifth  day,  pain  and 
fever  ceased,  improve- 
ment in  urine  and  an- 
aesthesia :  in  three 
months  could  stand 
erect  and  urinate. 

Slight  improvement  in 
sensation  on  second  day: 
hyperajsthesia  :  respira- 
tory troubles  :  wound 
almost  healed. 


Slight  improvement  in 
sensation  :  none  in  par- 
alysis :  bed-sore  healed : 
cystitis  recovered: 
wound  healed  in  seven 
days. 


Wound  healed  "without 
any  complication  what- 
ever." 

Wound  healed  on  ninth 
day :  no  change  in 
symptoms. 


On  following  day  wound 
doing  well  :  sensation 
had  returned  to  con- 
siderably below  the 
knees :  breathing  sud- 
denly became  embar- 
rassed :  cyanosis :  fail- 
ure of  respiration. 


Result. 


Completely 
cured  in  six 
months. 


Death  in 
seventy  hours. 


Partial 
recovery. 


Unrelieved. 


Death   on   se- 
cond day. 


Region  Affected  and 
Post-mortem  Appearances. 


Dislocation  of    twelfth 
dorsal  vertebra. 


Vertical  fracture  of 
fourtli  cervical :  ver- 
tebral canal  patent : 
cord  completely  di- 
vided opposite  fifth 
cervical  vertebra. 

Fracture  of  eleventh 
dorsal :  hsemato- 

myelia. 


Fracture  of  tenth, 
eleventh,  and  twelfth 
dorsal  arches  :  dis- 
placement forwards 
of  body  of  tenth,  not 
more  than  J  in. 

Fracture  of  third  and 
dislocation  forwards 
of  second  lumbar  ver- 
tebra :  displacement 
perfectly  reduced : 
Cauda  very  slightly 
bruised :  rupture  of 
diaphragm,  hernia  of 
stomach,  and  great 
omentum  into  left 
pleural  cavity,  &c. 

Death  due  to  other 
injuries. 


154 


SURGERY   OP  THE   SPINAL   CORD. 


No. 

Operator  and 
Date. 

Keference. 

Symptoms  before  Operation. 

Period  of 

Operation 

after  Injury. 

52 

Duncan. 

Edin.     Med.      Jour., 

Absolute  paraplegia  as  high 

Thirty-six 

1889. 

March  1889,  p.  832. 

as   groin:    retention   fol- 
lowed by  incontinence  of 
urine   and  faeces :    much 
collapsed :  great  extrava- 
sation of  blood  in  back : 
projection  of  second  lum- 
bar spine. 

days. 

53 

P^an. 

Hart,       Brit.      Med. 

Horse-bite  on  back,   appa- 

» 

1889. 

Journ.,   1889.     Vol. 
i.  p.  672. 

rently     only     a     slight 
"pinch    of     the    skin:" 
after  some  days  nervous 
symptoms  came  on  gradu- 
ally :  great  pain  in  back  : 
complete  paralysis  of  lower 
limbs :  retention  of  urine : 
prominence  of  sixtii  and 
depression  of  seventh  and 
eighth  dorsal  spines. 

54 

Allingham,  H. 

Brit.     Med.     Journ., 

"  Paralysed  from  below  the 

•> 

1888. 

1889.    Vol,  i.  p.  838. 

level  of  the  ensiform  car- 
tilage;"     "seemed      to 
lose  ground." 

55 

Allingham,  H. 
1888. 

Ibid. 

"  Paralysed    from    a    level 
seven    inches    above    the 
umbilicus." 

Six  days. 

56 

Dawbarn. 

New  York  Med.  Jour. , 

Complete  parai^legia,  begin- 

Six 

1889. 

June  29th,  1889,  p. 
711. 

ning  a  few  inches  below 
the  ribs:  involuntary  de- 
fsecation  :    retention    and 
overflow  of  urine :  cystitis : 
anaesthesia  as  high  as  um- 
bilicus, except  over  toes, 
where  was  slight  sensation : 
projection  of  twelfth  dor- 
sal spine,  depression  and 
deflection  to  left  of  ele- 
venth :    no  improvement 
during  one  month. 

months. 

INDICATIONS   FOR    OPERATIVE   TREATMENT. 


155 


Nature  of  Opera- 
tion. 


Removal  of 
arches  of  first 
three  lumbar 
vertebrae  : 
parts  much 
matted  t  o- 
gether  :  first 
lumbar  dis- 
placed for- 
wards about 
an  inch  :  cord 
torn  half 
through  and 
bent  twice  at 
a  right  angle : 
sheath  above 
and  below  in- 
jured region 
sewn  together, 
relaxing  latter 
portion:  some 
cerebro-  spinal 
fluid  escaped. 

Exposure  of  the 
arches,  which 
were  commi- 
nuted :  ten 
fragments  re- 
moved from 
the  spinal 
cord. 


Removal  of  fifth, 
sixth,  and 
seventh  dorsal 
laminae  expos- 
ing cord:  anti- 
septic treat- 
ment. 

Removal  of 
third,  fourth, 
fifth, and  sixth 
dorsal  lami- 
na: dura 
opened. 

Removal  of 
tenth,  ele- 
venth, and 
twelfth  dorsal 
arches :  dura 
not  opened : 
cord  bent  at 
angle  of  15° : 
anti  -septic 
dressing. 


Subsequent  Course. 


No  improvement  up  to 
seventeenth  day  :  free 
flow  of  cerebro-spinal 
fluid,  which  began  to 
diminish  in  a  week,  but 
was  still  continuing  on 
seventeenth  day. 


"Patient  is  now  restored 
to  almost  his  ordinary 
condition." 


Healing  of  wound  in  ten 
days :  some  improve- 
ment, "  the  level  of  the 
paralysis  being  brought 
down  to  the  umbilicus." 


Wound  healed  in  about  a 
fortnight  :  bed-sores : 
cystitis,  &c. 


Wound  soon  healed:  after 
ten  weeks,  pain  had 
ceased :  more  power  over 
bladder  and  rectum : 
some  return  of  power 
in  sartorii :  readier  re- 
sponse of  muscles  of 
limbs  to  electricity : 
limbs  became  warmer 
in  a  few  hours. 


Result. 


Unknown. 


Recovery. 


Partial  (slight) 
improvement. 


Death  in  seven 
months. 


Slight 
improvement. 


Region  Affected  and 
Post-mortem  Appearances. 


Dislocation  of  first  lum- 
bar vertebra:  fracture 
of  second. 


Middle  dorsal. 


Depression  and  fracture 
of  sixth  dorsal  lami- 


Cord  almost  divided : 
"both  ends  tapering 
down  to  a  fine  point." 


Junction  of  eleventh 
and  twelfth  dorsal 
vertebrae. 


156  SUEGERY    OF   THE   SPINAL    CORD. 

Such  being  the  available  clinical  evidence,  we  are  now  in  a 
position  to  consider  the  question,  how  far  is  the  future  practice  of 
this  operation  advisable  ?  In  the  first  place,  we  may  clear  the 
ground  somewhat  by  stating,  as  beyond  dispute,  that  in  cases  of 
compound  fractures  of  the  arches  (chiefly  gunshot  wounds),  foreign 
bodies  and  bony  fragments  should  be  removed,  and  the  wound 
treated  antiseptically.  No  possible  harm  can  accrue  from  so 
obvious  a  procedure,  which  was  apparently  first  practised  by 
Louis.  In  the  above  Table  cases  of  this  nature  have  not  been 
included,  and  they  need  not  now  be  further  referred  to. 

Taking  all  other  cases  together,  we  may  arrive  at  a  decision 
after  answering  the  following  series  of  questions:  (i.)  How  far 
are  spinal  injuries  curable  without  operation?  (2.)  Is  the  opera- 
tion itself  necessarily  fatal,  or  so  dangerous  as  to  be  unjustifiable  ? 
(3.)  If  successful,  is  it  likely  to  leave  the  vertebral  column  in 
a  condition  too  weak  to  perform  its  functions  ?  (4.)  Does  the 
operation  hold  out  a  prospect  of  improvement  in  all  or  any  cases  ? 
and  if  the  latter,  in  what  cases  ?    Let  us  take  these  points  seriatim. 

I.  Are  the  results  of  fractures  and  dislocations  of  the  spine 
incurable  without  operation  ?  Practically,  we  may  say  that  the 
vast  majority  are.  Gurlt  records  217  deaths  out  of  a  total  of 
270  fractures;  but  even  when  there  is  "recovery,"  there  are 
usually  persistent  nervous  symptoms  which  render  life  little  but 
a  burden,  and  which  would  warrant  extreme  measures  for  their 
relief.  There  are  also  among  these  recoveries  fractures  of  the 
vertebrae,  in  which,  owing  to  the  cord  not  having  been  involved, 
no  nervous  symptoms  are  produced ;  but  for  these  no  one  would 
suggest  trephining,  and  they  cannot  influence  the  decision  in  cases 
of  injury  to  the  cord.  A  few  cases  remain,  and  they  are  very 
few,  in  which  a  fairly  satisfactory  recovery  is  made,  and  in  which 
we  should  not  be  inclined,  for  the  relief  of  such  slight  symptoms 
as  remain,  to  subject  the  patient  to  a  major  operation.  It  will, 
however,  be  found  that  in  all  such  cases  recovery  sets  in  early,  pro- 
bably within  a  few  days  of  the  accident,  and  that  such  recovery 
is  progressive,  so  that  when  the  process  has  once  been  checked, 
we  find  no  further  change  for  the  better,  however  long  the 
patient  survive.  These  are  obviously  cases  in  which  there  is 
no  permanent  source  of  compression  of  the  cord,  but  in  which 
probably  a  diastasis  or  partial  luxation  of  the  vertebrae  has  pro- 
duced a  contusion  of  the  cord  or  of  its  nerve-roots.  We  may 
conclude,  then,  that  in  a  small  percentage  of  cases,  in  which 
the  symptoms  indicate  only  a  partial  transverse  lesion  of  the 
nervous    structures,  recovery    may  begin    shortly    and    progress 


INDICATIONS   FOR   OPERATIVE    TREATMENT.  1 57 

steadily.  In  these  cases  we  do  not  require,  and  therefore  should 
not  practise,  an  operation.  In  all  others — in  cases  in  which  the 
transverse  lesion  is  complete,  in  which,  although  it  be  partial  only, 
there  are  no  signs  of  improvement  within  a  week  or  two,  or  in 
which  improvement,  after  having  gone  on  steadily  for  a  time, 
comes  to  a  standstill — recovery  will  not  ensue.  For  these  cases 
trephining  might  be  practised  in  the  absence  of  any  other  means 
of  relief. 

II.  Is  the  operation  necessarily  fatal,  or  so  dangerous  as  to  be 
unjustifiable  ?  Necessarily  fatal  it  obviously  is  not,  and  under 
modern  conditions  it  does  not  appear  to  be  a  very  dangerous 
procedure.  Of  the  above  total  of  sixty-one  cases,  including  five 
original  and  fifty-six  quoted,  only  thirty-five  are  recorded  as 
deaths,  or  about  fifty-seven  per  cent., — a  proportion  comparing 
favourably  with  the  eighty  per  cent,  of  deaths  in  Gurlt's  analysis 
of  fractures  not  operated  upon,  and  which  is  only  raised  to  sixty- 
seven  per  cent.,  even  if  we  regard  the  six  cases  in  which  the 
result  is  unknown  as  having  all  ended  fatally.  Such  figures, 
however,  regarded  apart  from  contingent  circumstances,  hardly 
give  us  a  fair  estimate  of  the  danger  incurred  by  operating.  The 
majority  of  the  fatal  cases  were  evidently  doomed  apart  from  the 
operation,  and  in  but  few  could  the  latter  be  regarded  as  the 
cause  of  death.  More  to  the  point  is  the  fact  that  physiolo- 
gists have  very  frequently  trephined  the  spines  of  animals,  and 
that  in  such  cases  untoward  results  are  unusual.  As  throwing 
some  further  light  on  the  question,  I  have  made  an  analysis 
of  twenty  undoubted  cases  of  wounds,  by  sharp  instruments,  to 
the  cord  or  its  membranes,  in  human  beings,  and  among  these 
we  find  only  five  deaths.  If  we  reflect  that  these  wounds  were 
made,  not  by  the  surgeon,  but  by  accident,  and  that  many  were 
not  treated  antiseptically,  we  must  conclude  that  the  only  special 
danger  of  the  operation,  septic  meningitis  or  myelitis,  has  been 
much  exaggerated.  Hence  it  would  appear  that  the  dangers  of 
the  operation  are  comparatively  not  great,  especially  in  view  of 
the  conditions  which  it  is  designed  to  relieve. 

III.  It  has  been  argued  that  even  a  successful  operation  would 
leave  the  vertebral  column  so  weakened  as  to  be  unable  to  per- 
form its  functions  as  a  support  to  the  body  or  a  protection  to 
the  spinal  cord.  This  contention  is  at  once  disposed  of  by  the 
records  of  cases  which  have  survived.  In  no  single  instance 
has  such  a  difficulty  been  encountered.  There  is,  moreover,  no 
reason  why  the  spinal  envelope  should  not  be  strengthened  by 
the    re-implantation    of    such    vertebral    arches    as    have    been 


158  SURGERY    OF   THE   SPINAL    CORD. 

elevated,  a  procedure  which  has  been  successfully  adopted  by 
Mr.  Wright  in  a  case  of  spinal  caries  {infra). 

IV.  Does  the  operation  hold  out  any  prospect  of  recovery  in 
all  or  any  cases  ?  and  if  the  latter,  in  what  cases  ?  Even  when 
we  have  established  the  incurability  of  crushes  of  the  cord  apart 
from  trephining  and  the  practicability  of  that  operation  itself, 
it  will  be  necessary  before  adopting  it  to  give  an  aflSrmative  reply 
to  this  question ;  and  here  it  is  that  the  main  difficulty  arises. 
Post-mortem  evidence  shows  that  three  conditions  may  be  met 
with  as  the  early  results  of  a  crush  of  the  spinal  cord,  due  to 
fracture  or  dislocation  of  the  body  of  a  vertebra.  In  many  cases — 
I  should  be  inclined  to  say  in  the  majority  of  cases — there  is  not 
found  any  serious  narrowing  of  the  vertebral  canal  after  death. 
The  displaced  bones  commonly  fall  back  immediately  after  the 
injury  into  their  original  position,  leaving  the  contused  cord  free 
from  pressure.  In  other  cases  the  displacement  of  the  bones  is 
maintained,  and  the  cord  is  compressed,  usually  between  the  body 
of  the  lower  and  the  arch  of  the  upper  of  the  affected  vertebraB. 
In  a  small  minority  of  cases  pressure  upon  the  cord  is  due  solely 
to  the  effusion  of  blood.  In  the  first  group  of  cases  operation 
is  clearly  useless ;  the  whole  mischief  is  already  done  and  the 
cord  is  in  as  favourable  a  position  for  repair  as  can  be  supplied  to 
it.  In  the  second  and  third  groups  only,  can  we  by  operation 
remove  the  source  of  pressure,  and  for  the  present  we  may  neglect 
the  few  cases  constituting  the  third  group.  We  have,  therefore, 
to  ask  ourselves  what  benefit  is  to  be  derived  from  relieving  the 
cord  from  the  pressure  of  a  permanently  displaced  vertebra. 

There  is  here  2i  prima  facie  probabilitythat  nothing  will  be  gained. 
It  can  hardly  be  doubted  that,  when  the  bones  are  continuing  to 
press  upon  the  cord,  the  mischief  done  to  it  will  be  at  least  as 
severe  as,  probably  more  severe  than,  it  is  in  those  cases  in  which 
they  are  not.  But  as  these  latter  rarely  recover,  in  spite  of  the 
comparatively  favourable  conditions,  it  is  highly  improbable  that 
the  former  wUl  do  better  after  trephining.  In  other  words,  clinical 
evidence  points  to  the  fact  that  the  damage  done  by  an  acute 
compression  of  the  cord  is  usually  irreparable — that  the  cord  is 
incapable  of  repairing  an  extensive  crush.  Cases  of  ha^matomyelia 
point  to  the  same  conclusion :  life  may  be  spared,  but  rarely,  if 
ever,  are  no  permanent  symptoms  produced,  simply  because  the 
structures  immediately  destroyed  by  the  haemorrhage  undergo  no 
regeneration;  and  therefore,  if,  as  in  severe  crushes,  there  be  a 
practically  complete  transverse  haemorrhage,  there  will  result  a 
permanent  complete  transverse  lesion.     In  face  of  these  facts  it 


INDICATIONS    FOR    OPERATIVE    TREATMENT.  159 

is  useless  to  point  to  experiments  upon  animals  in  which  the 
structure  and  functions  of  the  cord  are  said  to  have  been  more 
or  less  restored  after  section ;  the  more  so  as  the  results  of 
such  experiments  are  still  open  to  doubt.  In  human  beings, 
as  in  animals,  clean  sections  are  capable  of  repair.  Among  the 
twenty  cases  of  wounds  by  sharp  instruments  to  which  I  have 
already  referred,  there  are  eighteen  in  which  the  cord  appears  to 
have  been  more  or  less  divided.  In  four  of  these  complete  reco- 
very ensued,  at  intervals  of  two  months  and  upwards ;  and  in  six 
there  was  partial  recovery ;  in  one  the  record  ceases  on  the  tenth 
day,  when  improvement  was  clearly  in  progress.  But  there  is  a 
wide  difference  between  a  clean  cut  and  the  effects  of  a  crush ; 
and,  as  has  been  indicated,  the  latter  appears  to  be  hopeless.  The 
fact  remains  that  a  certain  amount  of  improvement  may  follow  a 
crushing  lesion,  due  probably  to  the  recovery  of  those  portions  of 
the  cord  structure  that  have  only  been  compressed  and  not  de- 
stroyed by  the  haemorrhage ;  but  it  appears  highly  improbable 
that  any  such  tissue  will  remain  to  a  cord  permanently  flattened 
by  displacement  of  the  body  of  a  vertebra. 

Trephining  has  been  strongly  urged  by  Dr.  Brown-S^quard 
and  others,  on  the  ground  that  the  more  serious  symptoms  of  a 
crush  are  not  paralytic,  but  irritative,  and  that  operation  will  re- 
move the  source  of  irritation.  Into  this  somewhat  doubtful  ques- 
tion I  do  not  propose  now  to  enter,  further  than  to  say  that  clinical 
experience  does  not  seem  to  confirm  this  view.  The  trophic 
troubles  which  result  from  those  injuries  in  which  exaggeration  of 
reflexes  and  other  symptoms  would  indicate  irritation  are  not  more 
severe  than  those  found  in  cases  in  which  every  other  symptom 
points  to  a  pure  paralysis,  and  paralytic  lesions  may  undoubtedly 
give  rise  to  the  vascular  changes  which  accompany,  even  if  they 
do  not  cause,  such  trophic  troubles.  But  even  where  we  have  evi- 
dence of  irritation,  we  have  no  proof  that  it  is  due  to  the  pressure 
of  displaced  bone.  Thus  in  Case  1 1  (p.  26)  there  were  marked 
evidences  of  such  irritation,  and  yet  the  post-mortem  showed  that 
there  was  no  bony  pressure  upon  the  cord,  and  that  the  mischief 
arose  entirely  from  haemorrhage  and  subsequent  inflammation.  As 
above  stated,  I  have  seen  but  one  other  case  in  which  there  was 
early  increase  in  the  knee-jerk,  probably  indicating  irritation 
of  the  reflex  centres,  and  there  other  symptoms  showed  con- 
clusively that  the  injury  done  to  the  cord  was  comparatively 
slight,  and  recovery  ensued  without  operation.  Hence,  even  if 
we  grant  the  lesion  to  be  irritative,  we  cannot  expect  to  remove 
the  source  of  irritation  of  the  cord  by  trephining  the  spine ;  both 


l6o  SURGERY   OF   THE   SPINAL   CORD. 

the  irritation  and  the  paralytic  effects  are  equally  the  result  of  a 
lesion  of  the  nervous  structures,  which,  once  produced,  is  inde- 
pendent of  the  position  of  the  vertebrae. 

On  these  grounds,  then,  it  would  appear  that  no  benefit  can 
result  from  operating  for  most  traumatic  injuries  to  the  spinal 
cord,  and  that  operation  is  therefore  unjustifiable  in  such  cases. 

We  must,  however,  draw  an  important  distinction  between  the 
spinal  cord  and  its  nerve-roots.  The  structure  of  the  latter  is 
very  different  from  that  of  the  cord  itself,  and  they  must  be  con- 
sidered merely  as  peripheral  nerves.  As  such,  they  are,  in  the  first 
place,  far  more  resistant  to  compression.  An  injury  which  would 
convert  the  cord  into  a  mere  mass  of  blood-stained  pulp  might 
damage  a  nerve-trunk  very  slightly.  That  nerve-trunks  may  and 
do  recover  after  severe  injuries  is  a  fact  capable  of  daily  observa- 
tion. Even  complete  division  and  separation  of  the  ends  of  a  nerve 
is  no  barrier  to  its  recovery,  unless  some  other  tissue  intervene 
between  its  separated  portions  or  unless  the  latter  be  very  far  apart. 
And  even  in  the  latter  case  the  removal  of  the  obstacle  may  be, 
and  generally  is,  followed  by  reunion  at  dates  frequently  very 
remote  from  that  of  the  injury.  This  being  the  case  with  regard 
to  peripheral  nerves  elsewhere,  we  must  expect  the  same  results 
to  follow  in  the  case  of  injury  to  the  intraspinal  roots. 

Where  the  latter  run  in  contact  with  the  cord  itself,  the  above 
considerations  will  have  no  practical  bearing,  as  the  cord  lesion 
far  transcends  in  importance  that  of  its  associated  roots.  But 
below  the  lower  border  of  the  first  lumbar  vertebra  we  have  a 
region,  frequently  injured,  in  which  the  spinal  roots  have  still  a 
long  intraspinal  course,  but  in  which  the  cord  has  no  place. 
Here  then  we  have  a  new  condition — a  region  in  which  a  spinal 
injury  implicates  peripheral  nerves  only,  and  in  which  we  may 
on  d  priori  grounds  hope  to  do  much  by  relieving  these  nerves 
from  pressure.  We  may  also  assume  that,  in  injuries  of  the 
Cauda  equina,  if  the  symptoms  be  permanent,  they  are  due  to 
some  removable  source  of  pressure,  as  to  displaced  bone  or 
cicatricial  tissue.  Were  the  injury  a  contusion  melrely,  these 
roots  would  doubtless  spontaneously  recover  their  functions,  as  do 
other  peripheral  nerves  so  injured. 

These  theoretical  considerations  are  confirmed  by  the  statistics 
of  recorded  cases.  Thus  of  the  sixty-one  cases  collected,  sixteen 
appear  to  have  "partially"  or  wholly  recovered,  there  being  two 
complete  recoveries  only,  viz..  Cases  53  and  46.  Omitting  for 
the  moment  Case  53,  which  will  be  subsequently  referred  to, 
we  thus  find  fifteen  more  or  less  satisfactory  results.      Of  these 


INDICATIONS    FOR    OPERATIVE    TREATMENT.  l6l 

fifteen,  one  is  our  fourth  case  (p.  94),  in  which  the  lesion 
clearly  involved  only  the  cauda  equina.  The  others  are  Cases  8, 
12,  15,  17,  18,  23,  27,  39,  40,  45,  46,  48,  54,  and  56  of  the 
Table.  Of  these,  the  region  of  injury  is  unknown  in  Cases  17, 
39,  and  40,  thus  leaving  for  consideration  eleven  cases  only  from 
which  we  can  derive  any  information  of  value,  and  of  the  latte 
again.  Case  8  is  a  record  of  somewhat  doubtful  validity.  Cases 
15,  23,  and  54  are  injuries  above  the  lumbar  region,  but  in 
Case  I  5  the  operation  was  performed  the  day  after  the  accident, 
and  there  is  not  the  slightest  indication  that  the  patient  would 
not  have  progressed  equally  well  without  it,  and  in  Gases  23  and 
54  the  evidence  of  real  improvement  is  slight.  The  only  in- 
stances, therefore,  in  which  the  locality  of  the  injury  is  known, 
and  in  which  there  would  appear  to  have  been  a  hona  fide  im- 
provement, are  Cases  12,  18,  27,  45,  46,  48,  and  56,  in  which 
the  injury  affected  respectively  one  of  the  lumbar  vertebrae,  the 
sacrum,  the  twelfth  dorsal  or  first  lumbar,  the  twelfth  dorsal,  the 
junction  of  the  twelfth  dorsal  and  first  lumbar,  the  eleventh  dorsal, 
and  the  junction  of  the  two  last  dorsal  vertebrae.  Of  these 
seven,  the  two  first  almost  certainly  affected  the  cauda  only ;  in 
the  third  the  termination  of  the  cord  was  probably  injured,  and 
clearly  the  terminal  region  (supplying  the  bladder  and  rectum)  did 
not,  as  regards  the  latter  at  any  rate,  share  in  the  recovery ;  to 
the  fourth  (45)  the  same  remark  applies;  in  the  sixth  (48)  the 
partial  recovery  is  probably  due  entirely  to  the  nerve-roots,  and 
not  to  the  cord ;  in  the  seventh  (56)  the  improvement  was  almost 
trivial ;  and  in  one  only  (46)  is  there  anything  like  satisfactory 
evidence  of  recovery  of  any  portion  of  the  spinal  cord  itself. 

It  would  appear,  then,  that  we  may  sum  up  as  follows  :  That 
the  operation  of  trephining  the  spine  for  traumatic  lesions,  as 
compared  with  the  condition  which  it  is  intended  to  relieve,  does 
not  present  any  very  great  dangers,  and  appears  unlikely  to 
increase  the  gravity  of  the  prognosis,  but  that  as  both  a  priori 
argument  and  the  results  of  published  cases  show  that  it  is 
unlikely  to  be  of  service,  it  should  be  abandoned,  except  in  cases 
of  injury  to  the  cauda  equina,  and  that  in  the  latter,  on  the  other 
hand,  it  will  probably  prove  to  be  an  eminently  justifiable  and 
serviceable  procedure. 

But  even  in  inj  uries  of  the  cauda  equina  we  are  not  called  upon 
to  operate  in  every  case.  Many  of  these  will  progress  most  favour- 
ably or  recover  completely  without  any  interference ;  and  if  there 
seems  to  be  a  fair  prospect  of  such  recovery,  our  treatment  should 
be  expectant.     Both  from  the  evidence  of  the  cases  given  above 

L 


1 62  SURGERY   OF   THE   SPINAL   CORD. 

and  from  that  supplied  by  the  results  of  injuries  to  nerve-trunks 
elsewhere,  it  would  appear  that  the  chances  of  recovery  are  not 
seriously  diminished  by  postponing  operation  for  a  reasonable 
time.  Before  we  interfere,  we  should  therefore  be  assured  that 
nature  will  not  effect  a  cure.  Experience,  however,  shows  that 
if  spontaneous  recovery  is  about  to  take  place,  it  will  not  be  very 
long  in  commencing,  and  will  follow  a  fairly  continuous  course. 
Under  these  circumstances,  I  should  be  inclined  to  lay  down  the 
rough  rule,  that  if  at  the  end  of  six  weeks  there  is  no  recovery, 
or  if  recovery  is  at  a  standstill,  then,  and  then  only,  should  we 
operate  for  crushes  of  the  cauda  equina. 

Another  and  very  different  class  of  exceptions  to  the  doctrine 
of  non-intervention  in  injuries  to  the  spinal  cord  is  furnished  by 
those  cases  in  which  the  injury  has  affected  not  the  bodies,  but 
the  arches  of  the  vertebrae.  In  the  latter  the  pathological  con- 
ditions differ  entirely  from  those  found  in  the  former.  The  crush 
of  the  cord  is  obviously  not  liable  to  be  so  severe  where  the 
laminae  only  are  depressed,  as  it  is  when  the  entire  vertebra  is 
displaced  and  the  cord  is  subjected  to  the  weight  of  a  consider- 
able portion  of  the  body.  In  pure  fractures  of  the  laminae,  also, 
the  consideration  that  the  bones  have  probably  at  once  regained 
their  normal  position,  and  that  the  cord  has  thus  been  placed  in 
the  most  favourable  position  for  recovery,  has  less  weight,  for  these 
structures  are  frequently  tightly  w^edged  after  injury,  and  are  not 
subject  to  the  natural  extending  forces  of  elasticity,  of  muscular 
action,  and  of  the  body  weight.  Thus  the  cord,  having  once  been 
jammed,  the  pressure  is  more  liable  to  be  maintained.  Again, 
a  tightly  wedged  lamina  will  be  subject  to  movement  with  every 
movement  of  the  body,  and  will  then  be  continually  engaged 
in  further  ploughing  up  the  cord.  We  may  therefore  hope  to 
improve  the  patient's  chances  of  recovery  by  the  removal  of  a 
depressed  arch,  and  the  above  considerations  regarding  the  risks 
of  the  operation  must  lead  us  to  the  conclusion  that  such  a  pro- 
ceeding is  here  justifiable.  In  such  cases,  also,  we  should  act  with- 
out delay,  as  we  cannot,  as  in  the  case  of  the  cauda  equina  and  the 
peripheral  nerves,  trust  to  the  long  retention  of  any  capacity  for 
regeneration  which  may  be  present  in  the  structures  involved, 
and  as  there  is  the  constant  danger  of  the  infliction  of  further 
damage  upon  movement. 

A  successful  result  in  a  case  of  this  nature  was  obtained  by 
P^an.  A  man  received  a  bite  from  a  horse  in  the  mid-dorsal 
region,  which  was  at  first  supposed  to  be  only  a  "pinch  of  the 
skin."     After  some  days  nervous  symptoms  began  to  come  on 


INDICATIOKS    FOR   OPERATIVE   TREATMENT.  1 63 

gradually,  and  culminated  in  complete  paraplegia,  retention  of 
urine,  and  severe  local  pain.  After  an  interval,  of  which  the 
duration  is  not  recorded,  Pean  found,  in  addition  to  the  above 
symptoms,  a  depression  of  the  seventh  and  eighth  dorsal  spinous 
processes.  Cutting  down  upon  these,  he  removed  about  ten 
fragments  which  had  entered  the  spinal  cord,  and,  without  any 
complication,  the  patient  was  "  restored  to  almost  his  ordinary 
condition."  The  course  of  events  in  this  case  is  not  very  clear, 
as,  had  the  fragments  been  at  once  driven  into  the  cord,  which 
seems  to  be  assumed  in  the  report,  the  nervous  symptoms  would 
have  been  immediately  produced.  Probably,  therefore,  the  broken 
arches  were  secondarily  depressed  by  movement  or  pressure ;  but 
however  this  may  have  been,  the  case  illustrates  the  advantages 
which  may  result  from  the  excision  of  bony  spiculae  actually  in 
contact  with  or  penetrating  the  spinal  cord,  when  the  latter  is 
not  crushed  beyond  repair. 


Section  II. — Caries  of  the  Vertebrae. 

Ashhurst  ^  states  incidentally  that  portions  of  the  vertebrse 
were  removed  "for  disease"  by  Heine,  Roux,  Holscher,  and 
Dupuytren,  but  I  have  been  unable  to  find  the  records  of  these 
cases,  and  the  first  operation  of  this  nature  with  which  I  am  ac- 
quainted is  that  performed  by  Jackson  in  1882,  since  which  time 
several  similar  cases  have  been  subjected  to  the  same  procedure. 
All  of  these  have  been  collected  in  the  following  table :  — 

^  Loc.  cit.,  p.  56. 


1 64 


SUEGERY    OF   THE   SPINAL   CORD. 


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INDICATIONS.  FOR   OPERATIVE   TREATMENT. 


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INDICATIONS    FOR   OPERATIVE   TREATMENT.  1 67 

The  results  of  these  thirteen  operations  are  as  follows.  In 
two  only  (5  and  12)  does  the  operation  appear  to  have  done 
harm;  in  three  (6,  7,  and  13)  no  relief  was  afforded;  in  one 
(9)  marked  improvement  resulted,  but  a  relapse  occurred,  pro- 
bably from  recurrence  of  the  inflammatory  compression ;  and  in 
the  remaining  seven  we  have  most  obvious  relief.  The  clinical 
history  of  the  latter  group  demonstrates  clearly  that  this  relief 
was  a  direct  result  of  the  operation,  and  was  not  due  to  a  chance 
connection.  From  these  figures  then  we  deduce  at  once  the 
conclusion  that  in  certain  of  these  cases  surgical  interference  is 
of  undoubted  value,  and  it  remains  only  to  ask  what  are  the  indi- 
cations for  the  operation. 

It  is  generally  recognised  that  the  nervous  phenomena  result- 
ing from  spinal  caries  are  not  due  to  the  mere  curvature  of  the 
spine  ;  that  the  latter  leaves  the  vertebral  canal  little,  if  at  all, 
diminished  in  size ;  and  that  the  implication  of  the  cord  arises 
from  some  other  cause.  It  is  equally  certain  that  the  lesion  is 
not  in  most,  if  in  any,  cases  an  acute  myelitis,  but  rather  a 
result  of  pressure,  to  which  the  changes  in  the  cord  structure 
itself  are  secondary.  This  pressure  may  be  exercised  by  solid 
fungating  masses  springing  from  the  bodies  of  the  vertebrae, 
or  by  acute  inflammatory  swelling  or  haemorrhage  in  connection 
with  the  meninges,  but  by  far  most  frequently  it  is  the  result  of 
a  chronic  thickening  of  the  latter.  Hence,  then,  although  other 
causes  may  be  at  work,  much  the  most  common  is  chronic 
localised  pachymeningitis  compressing  the  implicated  section  of 
the  cord.  This  conclusion  is  adopted  by  most  writers  upon  the 
subject,^  and  is  in  accordance  with  the  writer's  own  experience 
of  a  considerable  number  of  post-mortem  examinations. 

It  follows,  therefore,  that  we  may  best  hope  to  relieve  these 
nervous  phenomena  in  those  cases  in  which  they  are  of  compara- 
tively slow  onset,  although  it  may  be  possible,  as  was  attempted 
in  Case  7,  to  extend  the  operation  to  more  acute  cases  of  com- 
pression by  suppuration  or  by  haemorrhage.  The  chances  of 
success  in  such  an  operation  must  be  regarded  as  very  doubtful, 
but  we  cannot  yet  say  that  it  may  not  have  its  uses.  Up  to 
the  present  time,  however,  benefit  has  ensued  only  in  cases  of 
chronic  pachymeningitis,  a  limitation  of  the  scope  of  the  opera- 
tion implied  also  in  Mr.  Macewen's  rejection  of  cases  in  which 
there  is  rise  of  temperature.  Having  thus  a  clear  idea  of  the 
condition  which  we  hope  to  relieve,  two  other  considerations  only 
are  necessary.  Of  these,  the  most  obvious  is  that  we  must 
'  Elliott,  New  York  Med.  Jour.,  June  2,  18S8. 


l68  SURGERY   OF   THE   SPIKAL   CORD. 

freely  remove  the  thickened  perimeningeal  connective  tissue, 
and  that  only  when  this  has  been  done  can  we  hope  for  any 
good  result.  The  other  is  that  paralysis  secondary  to  spinal 
caries  has,  even  when  of  long  duration,  a  remarkable  tendency 
to  recovery,  if  the  recumbent  position  be  rigorously  maintained, 
and  that  we  must  therefore  not  operate  too  early,  but  must  first 
be  convinced  that  no  improvement  will  result  without  such  inter- 
vention, the  more  so  as  the  frequent  occurrence  of  late  recovery 
itself  indicates  that  we  are  not  seriously  diminishing  our  chances 
of  success  by  such  delay. 

Section  III. — Other  Pressure  Lesions. 

It  having  once  been  proved,  as  it  has  been,  that  the  operation 
of  trephining  the  spine  falls  within  the  range  of  practical  surgery, 
and  that  chronic  pressure  lesions  of  the  cord  are,  even  after  long 
duration,  susceptible  of  very  great,  if  not,  in  some  instances,  per- 
fect recovery,  it  follows  that  the  operation  is  practicable  and 
advisable  in  any  such  disease  in  which  the  source  of  pressure  is 
accessible  for  removal,  and  is  not  amenable  to  other  methods  of 
treatment. 

In  the  case  of  tumours  of  the  membranes  or  nerve-roots,  this 
has  been  demonstrated  in  the  most  practical  manner  possible  by 
Mr.  Horsley's  brilliant  operation,  and  obviously  that  which  can 
be  done  for  intravertebral  tumours  can  be  equally  well  done  in 
the  case  of  tumours  of  the  vertebrae  themselves,  and  tumours 
growing  into  the  spinal  canal  from  other  regions,  provided 
that  the  anatomical  connections  of  these  growths  are  not  such 
as  to  preclude  removal.  An  interesting  case  of  this  nature  has 
recently  been  operated  upon  in  the  Manchester  Infirmary  by  Mr. 
Wright,  who  is  reserving  a  full  report  until  after  the  lapse  of  a 
longer  period,  but  who  has  kindly  permitted  me  to  use  the 
following  notes : — 


Case  49. — Fibrosarcoma  of  neck  invohing  brachial  plexus  and 
invading  spinal  canal — Removal — Cure  of  spinal  symptoms. 

A.  H.,  aged  thirty-eight,  was  admitted  on  August  6,  1888, 
under  the  care  successively  of  Drs.  Morgan  and  Ross.  For 
some  twenty  years  he  had  noticed  a  slowly-growing  swelling  on 
the  left  side  of  his  neck.  Fifteen  months  before  admission  he 
first  observed  numbness  and  weakness,  of  progressive  character,  in 


INDICATIONS    FOIl   OPERATIVE   TREATMENT.  1 69 

the  left  arm ;  three  months  later  the  left  leg  began  to  fail,  and 
recently  the  right  arm  and  leg  had  been  losing  power.  There 
was  a  history  of  alcoholism,  but  not  of  syphilis  or  any  hereditary 
disease.  On  admission,  the  tumour  was  about  the  size  of  an 
orange,  seated  in  the  posterior  triangle  of  the  neck,  well  defined 
in  outline,  slightly  mobile,  firm  and  elastic ;  pressure  upon  it 
caused  pain  in  the  distribution  of  the  ulnar  nerve :  no  other 
growths  were  discovered.  The  left  arm  was  weak  and  the  muscles 
wasted,  the  flexors  of  the  wrist  and  fingers  and  intrinsic  muscles 
of  the  hand  being  mainly  affected  ;  "  claw-hand  "  was  well  marked; 
partial  anesthesia  affected  the  ulnar  side  of  the  forearm  and 
hand.  The  right  arm  was  also  weak,  but  without  atrophy  or 
impairment  of  sensation :  here  also  the  paresis  was  rather  more 
marked  in  the  flexors  of  the  wrist  and  fingers,  and  in  the  intrinsic 
muscles  of  the  hand.  The  deep  reflexes  at  the  wrist  and  elbow 
were  increased.  The  left  lower  limb  presented  the  usual  evi- 
dences of  spastic  paralysis :  the  right  was  but  slightly  weakened. 
The  left  eye  projected  a  little.  Pupils  normal.  General  health 
good.  Anti-syphilitic  and  other  treatment  proved  of  no  avail,  and 
all  the  above  symptoms  became  gradually  intensified.  The  spastic 
symptoms  extended  to  the  right  lower  extremity,  the  muscles  of 
both  lower  limbs  becoming  tonically  rigid ;  paralysis  increased, 
and,  on  the  left  side,  extended  to  the  upper  arm  muscles. 

On  August  2 1st,  1888,  the  tumour  in  the  neck  was  removed 
by  an  ordinary  dissection ;  it  was  about  the  size  and  shape  of  a 
lemon,  and  distinctly  encapsuled,  and  was  afterwards  found  to 
consist  chiefly  of  fibrous  tissue,  with  portions  which  were  clearly 
sarcomatous,  and  with  areas  of  myxomatous  degeneration.  A 
projection  penetrated  one  of  the  intervertebral  foramina,  appa- 
rently that  for  the  third  cervical  nerve,  and  the  base  of  this  pro- 
cess having  been  ligatured,  the  chief  mass  of  the  growth  was 
torn  away,  the  appendage  being  temporarily  left  in  situ.  A 
second  smaller  growth,  about  the  size  of  an  egg,  was  now  found 
lying  below  the  first,  and  this,  which  resembled  the  latter  in 
character,  was  also  removed.  Both  growths  were  connected  with 
the  cords  of  the  brachial  plexus.  Attention  was  next  turned  to 
the  projection  which  invaded  the  vertebral  canal.  The  implicated 
foramen  was  large  enough  to  admit  the  tip  of  the  little  finger, 
and  a  Volkmann's  spoon  being  thus  introduced  into  the  canal, 
the  growth  was  carefully  and  gently  scraped  away.  There  was 
no  haemorrhage  or  other  trouble,  and  the  spray,  with  other  anti- 
septic precautions,  was  used  throughout  the  operation. 

The  wound  was  healed  on  the  twentieth  day.    Nervous  symptoms 


170  SURGERY   OF   THE   SPINAL   CORD. 

were  almost  immediately  relieved.  On  the  day  after  the  opera- 
tion the  contractions  of  the  lower  limb  muscles  were  much 
slighter,  and  thereafter  they  ceased  entirely.  At  the  same  time  the 
lower  limbs  began  to  regain  power.  The  right  arm  also  increased 
markedly  in  power,  and  the  grasp,  which  had  been  almost  entirely 
lost,  became  quite  strong  again.  The  left  arm  improved  to  a 
less  extent,  but  the  forearm  muscles  regained  some  power,  whereas 
those  of  the  upper  arm  did  not.  The  improvement  thus  noted 
occupied  about  three  weeks,  after  which  the  patient  was  dis- 
charged. Some  time  later,  when  last  seen  by  Mr.  Wright,  he 
could  walk,  and  the  right  upper  limb  was  almost  well,  the  left 
in  statu  quo. 

There  can  be  little  doubt  that  the  growth  had  here  penetrated 
the  vertebral  canal  along  the  course  of  the  left  third  cervical 
nerve-root,  that  the  latter  had  been  comparatively  little  injured 
at  first,  but  that  on  entering  the  canal,  the  growth  had  more 
seriously  implicated  the  less  resistant  tissue  of  the  cord  itself, 
and  had  grown  across  the  anterior  aspect  of  the  latter.  In  this 
way  only  can  we  explain  the  comparatively  trivial  sensory  troubles, 
the  spastic  symptoms  in  the  upper  and  lower  limbs,  and  various 
other  minor  points.  The  chief  damage  was  no  doubt  done  to 
the  cords  of  the  left  brachial  plexus.  The  operation  greatly 
relieved  the  pressure  upon  the  cord,  but  the  damage  done  to  the 
roots  of  the  plexus  outside  the  spinal  canal  appears  to  have  been 
irreparable.  Although  the  case  is  not  one  of  "trephining  the 
spine,"  in  the  ordinary  sense  of  the  term,  it  falls  within  the 
category  of  intravertebral  operations,  and  illustrates  the  benefits 
to  be  derived  therefrom. 

It  remains  only  to  add  that  similar  procedures  may  clearly  be 
adopted  for  cysts,  for  otherwise  incurable  pachymeningitis,  for 
chronic  rheumatic  arthritis  of  the  vertebra3  with  compression  of 
the  cord,  and  possibly  for  certain  meningeal  hsemorrhages,  either 
at  an  early  stage,  when  life  is  directly  thi-eatened,  or  later,  should 
absorption  be  unsatisfactory.^ 

^  As  the  above  is  passing  through  the  press  there  has  appeared  a  report  by  Drs. 
Dercum  and  White  {Annals  of  Surgery,  June  1889)  of  two  cases  in  which  the  latter 
opened  the  spinal  canal.  In  the  first  the  diagnosis  is  obscure,  but  severe  nervous 
symptoms  recovered  shortly  after  the  operation,  in  which  the  dura  mater  was 
opened.  The  second  was  a  case  of  tubercular  pneumonia,  caries  of  the  vertebrae, 
and  acute  myelitis  :  death  ensued  within  thirty  hours  of  the  operation.  Dr.  Abbe 
{New  York  Med.  liec,  February  1SS9)  has  also  opened  the  spinal  canal  and  divided 
several  of  the  cervical  nerve-roots  close  to  the  dura  mater,  in  a  case  of  intractable 
neuralgia :  the  patient  survived  and  manifested  some  improvement  in  his  symptoms. 


CHAPTER  VIL 

OPHTHALMOSCOPIC  CHANGES  IN  INJURIES  OP  THE 
SPINAL  CORD  AND  IN  TRAUMATIC  NEUROSES. 

Few  subjects  have  been  less  investigated,  and  on  few  is  the 
information  which  we  possess  more  conflicting,  than  on  that  of 
the  changes  seen  in  the  fundus  oculi  after  injuries  to  the  spinal 
cord,  the  original  observations  upon  the  point  being  remarkably 
limited  in  number,  while  the  references  found  in  medical  literature 
are  mainly  more  or  less  accurate  expositions  of  the  work  of  but 
very  few  observers.  Under  these  circumstances,  I  have  thought 
it  worth  while  to  make  a  few  fresh  investigations,  and  to  compare 
the  results  with  the  conclusions  arrived  at  by  others. 

A  double  source  of  confusion  has  been  introduced  into  the  con- 
sideration of  this  subject — a  confusion  of  which  we  must  in  the 
first  instance  endeavour  to  divest  ourselves.  It  is  exceedingly 
common  to  find  after  severe  shocks  to  the  nervous  system  cer- 
tain eye-symptoms — retinal  irritability,  photophobia,  retinal  weak- 
ness, muscae  volitantes  and  other  subjective  phenomena,  dis- 
turbances of  accommodation  (especially  if  there  be  previous 
refractive  error),  weakness  of  the  internal  recti,  and  last,  but 
not  least,  more  or  less  complete  loss  of  vision,  with  marked 
restriction  of  the  visual  field.  These  conditions  are  recognised 
a,s  retinal,  accommodative,  or  muscular  asthenopia  and  as  "  hyste- 
rical "  amblyopia,  of  the  last  of  which  affections  several  instances 
will  be  mentioned  in  considering  traumatic  hysteria.  They 
are  all  purely  functional  troubles,  and  bear  no  relation  to 
any  organic  changes  in  the  fundus  oculi,  nor,  so  far  as  I  can 
find,  is  there  a  single  instance  on  record  in  which  such  symp- 
toms were  followed  by  optic  atrophy,  although  many  writers 
certainly  convey  the  impression  that  in  nearly  all  such  cases 
ophthalmoscopic  changes    eventually  supervene.^      Hence,  then, 

^   Cf.  Ericbsen,  Science  and  Art  of  Surgery,  8th  edit.,  London,  1884,  vol.  i.  p.  777. 


l*J2  SURGERY   OF   THE   SPINAL   CORD. 

at  the  outset,  superfluous  as  it  may  seem,  we  must  insist  upon 
the  truism,  that  the  existence  of  changes  in  the  optic  nerve 
or  disc  cannot  be  established  unless  objective  evidence  of  such 
change  be  forthcoming,  as  the  result  of  either  an  ophthalmoscopic 
or  a  post-mortem  examination,  and  that  the  presence  of  subjective 
visual  troubles  is  not  necessarily  any  indication  of  organic  disease. 

The  second  source  of  confusion  to  which  I  have  referred  is  that 
until  recently  it  has  been  customary  to  describe  as  "  concussion 
of  the  spine  "  a  large  number  of  cases  which  are  now  recognised 
as  neurasthenic  or  hysterical,  which  may  collectively  be  denomi- 
nated traumatic  neuroses  or  traumatic  neuro-psychoses,  and  which 
are  in  no  way  dependent  upon  lesions  of  the  spinal  cord.  Here 
again,  then,  we  must  reiterate  a  second  truism,  that  those  cases 
onl}'-  should  be  regarded  as  injuries  of  the  spinal  cord  in  which 
there  is  definite  evidence  of  some  lesion  of  that  structure. 

In  order  to  obviate  as  far  as  possible  these  two  initial  difficul- 
ties, which  appear  to  have  insensibly  crept  into  and  complicated 
the  descriptions  of  many  writers,  we  must  therefore  confine  our 
attention  strictly  to  cases  in  which  changes  in  the  fundus  are 
proved,  and  not  merely  inferred  to  exist ;  and  we  must  carefully 
distinguish  between  hona  fide  injuries  of  the  spinal  cord  on  the 
one  hand,  and  the  large  class  of  traumatic  neuroses  on  the  other. 
To  keep  clear  this  latter  important  distinction,  it  will  be  well  to 
discuss  separately  the  visible  optical  changes  :  first,  in  definite 
organic  lesions  of  the  spinal  cord;  second,  in  slighter  injuries  to 
the  back,  not  directly  implicating  the  spinal  cord,  and  unaccom- 
panied by  such  circumstances  as  cause  severe  shock  to  the 
nervous  system  ;  and  third,  in  injuries  of  which  the  local  con- 
ditions are  similar  to  the  last,  but  which  are  complicated  by  more 
or  less  severe  general  shock — i.e.,  practically,  railway  injuries. 

I. — Injuries  of  the  Spinal  Cord. 

In  the  above  pages  there  will  be  found  thirty-eight  personal 
observations  of  severe  injuries  to  the  spinal  cord,  the  records 
of  which  cases,  including  fractures,  dislocations,  and  haemor- 
rhages, constitute  the  basis  from  which  my  own  conclu- 
sions have  been  drawn.  Of  these  thirty-eight  cases,  seventeen 
were  injuries  below  the  level  of  the  third  dorsal  nerve-roots. 
In  none  of  the  seventeen  were  there  ever  any  subjective  eye- 
symptoms,^  and,  in  nine  at  least,  I  failed,  on  examining  the  discs, 

'  There  was  one  doubtful  case,  in  which,  however,  repeated  investigations  failed  to 
show  any  changes  in  the  fundus  (p.  123). 


OPHTHALMOSCOPIC   CHANGES.  I  73 

to  find  anything  abnormal.  Hence,  although  the  evidence  is 
purely  negative,  my  own  experience  would  appear  to  indicate  that, 
in  severe  injuries  below  this  level,  ophthalmoscopic  changes  do 
not  arise,  even  at  long  intervals  after  the  receipt  of  the  injury. 
The  majority  of  the  injuries  have  been  considerably  below  the 
third  dorsal  nerve,  but  the  considerations  which  follow  lead  us  to 
assign  to  the  upper  dorsal  region  the  dividing-line  between  cases 
which  do,  and  those  which  do  not,  give  rise  to  changes  in  the  disc. 

There  is,  however,  one  recorded  case  which  apparently  points 
in  an  opposite  direction.  Mr.  Bruce  Clarke  ^  reports  the  case  of  a 
man  who,  having  been  struck  by  a  falling  weight,  sustained  a  frac- 
ture of  the  fourth,  fifth,  and  sixth  dorsal  vertebrae,  with  complete 
division  of  the  cord  at  the  level  of  the  fifth  and  sixth,  dying  on 
the  tenth  day.  On  the  third  day  it  is  stated  that  "  there  is  well- 
marked  hyperaemia,  with  considerable  cedema  of  both  discs ;  a 
good  deal  of  effusion  obscures  the  vessels  in  many  places."  But 
here  it  was  noted  on  the  second  day  that  breathing  was  "  entirely 
diaphragmatic,"  and  on  the  third  that  there  was  well-marked 
hypergesthesia  of  the  chest ;  so  that  it  appears  highly  probable 
that  myelitis  had  rapidly  extended  for  a  considerable  distance 
above  the  injured  region,  and  had  reached,  at  least,  to  the 
extreme  upper  limit  of  the  dorsal  portion,  before  any  optical 
changes  were  found ;  from  which  it  would  follow  that  the  excep- 
tion is  apparent  rather  than  real,  and  that  the  eye-troubles  may 
be  traced  to  an  extension  of  the  cord  mischief  above  the  level  of 
the  dorsal  region. 

Very  different  results  are  obtained  from  a  study  of  cases  of 
injury  above  the  second  dorsal  nerve,  i.e.,  above  the  level  of  the 
"  cilio-spinal  centre."  The  twenty-one  cases  of  injury  in  the  cer- 
vical region  above  described  include  fifteen  of  fracture  or  disloca- 
tion, with  one  recovery,  and  six  of  intraspinal  haemorrhage,  four  of 
which  recovered,  and  in  one  of  which  (Case  21)  the  patient  lived 
for  eighteen  months  after  the  accident.  In  no  case,  either  of 
recovery  or  of  early  or  tardy  death,  did  any  subjective  eye-symptoms 
present  themselves,  and  we  may  therefore  assume  that  in  none 
were  there  any  very  serious  papillary  changes. 

In  seven  cases,  however,  we  have  definite  ophthalmoscopic  obser- 
vations, of  which  the  results  are  as  follows  : — 

I.  (Case  8.)  A  man,  aged  thirty-three,  was  struck  upon  the  back 
of  the  neck  by  a  weight,  receiving  a  fracture  of  the  fifth  and 
sixth  cervical  vertebrae,  with  dislocation  forwards  of  the  fifth,  and 
suffering  from  total  paralysis,  anaesthesia,  &c.,  below  the  level  of 

^  St.  Barth.  Hosp.  Rep.,  vol.  xvi.,  1880,  p.  171,  Case  4. 


174  SURGEKY    OF   THE   SPINAL    CORD. 

the  lesion.  He  died  on  the  seventh  day,  the  diagnosis  being  con- 
firmed by  post-mortem  examination.  I  examined  the  discs  on 
the  sixth  day,  finding  no  abnormality.  The  pupils  and  palpebral 
fissures  were  small,  and  the  former  did  not  dilate  upon  irritating 
the  skin  of  the  back  of  the  neck. 

2.  (Case  I  3.)  A  woman  died  in  forty  hours  from  fracture-dislo- 
cation between  the  sixth  and  seventh  cervical  vertebrae,  with  the 
usual  symptoms  of  a  crush  of  the  spinal  cord,  the  consequent 
paralysis  extending  rapidly  to  the  phrenic  roots.  The  lesion  was 
confirmed  by  post-mortem  examination.  I  examined  the  eyes 
within  twelve  hours  of  the  accident,  finding  the  right  disc  nor- 
mal ;  the  left  could  not  be  seen  owing  to  an  incipient  cataract. 
The  only  mobile  pupil  was  reduced  in  size. 

3.  (Case  14.)  A  man  died  in  thirty-one  days  from  a  dislocation 
of  the  last  cervical  vertebrge.  There  were  the  usual  symptoms 
of  a  crush  of  the  spinal  cord,  and  the  post-mortem  examination 
established  the  diagnosis.  On  the  seventeenth  day  I  found  both 
discs  normal  and  identical.  The  pupils  and  palpebral  fissures 
•were  contracted  on  both  sides,  but  especially  on  the  right,  where 
there  were  other  evidences  that  the  cervical  sympathetic  was  more 
severely  injured. 

4.  (Case  15.)  In  a  case  of  unilateral  dislocation  of  the  fifth 
cervical  vertebra,  with  incomplete  crushing  of  the  cord,  causing 
paralysis,  anaesthesia,  &c.,  below  the  injured  region,  the  disloca- 
tion was  reduced,  and  the  man  gradually  recovered  almost  com- 
pletely. I  examined  his  discs  on  several  occasions,  within  the  first 
few  weeks  after  the  accident,  without  finding  any  changes.  The 
pupils  and  palpebral  fissures  were,  as  usual,  diminished  in  size. 

In  these  four  cases,  then,  there  was  no  evidence  of  changes 
in  the  disc,  but,  as  we  shall  shortly  see,  the  examination  in  Case 
1 3  (and  perhaps  also  in  Case  8)  was  too  early,  and  that  in  Case  14 
too  late,  for  us  to  affirm  that  no  such  change  had  or  might  have 
arisen.  Case  i  5 ,  in  which  the  cord  injury  was  not  very  com- 
plete, is  the  only  one  in  which  we  may  safely  assume  that  the 
optic  discs  were  unaffected.     There  remain  three  other  cases. 

5.  (Case  10.)  A  man,  aged  thirty-three,  sustained  a  fracture 
of  the  sixth  cervical  vertebra,  with  dislocation  forwards  of  the 
fifth.  He  died  on  the  twenty-ninth  day,  and  the  post-mortem 
examination  confirmed  the  diagnosis.  The  symptoms  and  appear- 
ances were  those  of  a  crush  of  the  cord  in  the  region  named,  with 
myelitis  ascending  for  some  little  distance,  but  with  no  evidence 
of  basic  meningitis.  The  palpebral  fissures  and  pupils  were  small, 
and  the  latter  did  npt  dilate  on  pinching  the  skin  of  the  neck. 


OPHTHALMOSCOPIC   CHA^'GES.  1  75 

On  the  third  day  the  optic  discs  were  perfectly  normal.  On  the 
fifth  day  their  margins  were  less  well  defined  than  before,  and 
there  was  slight  congestion  of  the  retinal  veins.  On  the  sixth 
day  the  discs  were  still  more  hazy,  but  there  was  no  obscuring  of 
the  vessels  by  effusion.      Thereafter  they  were  not  examined. 

6.  (Case  I2.)  A  young  man  sustained  a  fracture  of  the  first 
dorsal  vertebra,  with  dislocation  forwards  of  the  seventh  cervical. 
He  died  on  the  tenth  day,  and  presented  the  symptoms  and  post- 
mortem appearances  of  a  crush  of  the  cord  at  the  region  referred 
to,  with  some  ascending  myelitis,  but  with  no  evidence  of  basic 
meningitis.  The  palpebral  fissures  and  pupils  were  contracted, 
and  the  latter  did  not  dilate  on  pinching  the  skin  of  the  back  of 
the  neck.  On  the  third  day  the  optic  discs  were  a  little  hazy  and 
ill-defined,  there  being  also  slight  venous  congestion  of  the  retina. 
On  the  fifth  day  the  same  symptoms  were  present,  but  there  was 
no  evidence  of  eff'usion.  On  the  ninth  day  the  discs  were  more 
indistinct  than  before,  and  the  smaller  vessels  were  quite  obscured 
by  exudation. 

7.  (Case  II.)  After  an  injury  to  the  spine  this  patient  pre- 
sented the  symptoms  of  a  crush  of  the  cord  above  the  level  of 
the  sixth  cervical  root,  followed  by  myelitis,  which  slowly  extended 
upwards  for  some  ten  days  and  then  ceased.  Improvement  now 
commenced,  and  for  another  fortnight  there  was  gradual  return 
of  power  in  some  of  the  muscles  of  the  upper  limbs,  after  which 
the  condition  was  unchanged.  On  the  fifty-sixth  day  the  laminae 
of  the  affected  vertebrae  were  removed  ;  the  myelitis  at  once  began 
to  reascend,  and  eight  days  later  the  patient  died.  He  had  no 
symptoms  of  basic  meningitis.  The  autopsy  confirmed  the  diag- 
nosis. Both  pupils  and  palpebral  fissures  were  contracted  through- 
out. On  the  second  and  third  days  after  the  accident,  he  had 
profuse  lachrymal  secretion,  with  congestion  of  the  conjunctivae 
and  flushing  of  the  face.  On  the  morning  of  the  third  day  the 
left  hand  was  warmer  and  redder  than  the  right,  and  in  the  even- 
ing the  condition  was  reversed ;  but  on  the  fourth  day  the  left 
was  again  redder  and  somewhat  congested.  On  the  sixteenth 
day  I  examined  the  discs  for  the  first  time,  and  found  them  both 
hazy,  with  ill-defined  outlines  and  doubtful  engorgement  of  the 
retinal  veins.  Two  days  later  I  could  find  no  abnormality  in  the 
right  disc,  but  the  left  was  still  hazy  as  before,  the  difference 
between  the  two  being  very  obvious.  On  the  following  day  Dr. 
Little  kindly  examined  the  ej'es,  and  found  the  right  disc  perfectly 
healthy,  whereas  "  the  left  was  hazy,  with  some  distensit)n  of  the 
vessels  and  haziness  aloncr  their  course."     Dr.  Little  had  no  doubt 


176  SURGERY    OF    THE   SPINAL   CORD. 

that  there  was  at  this  time  a  pathological  change  on  the  left  side, 
especially  in  view  of  the  difference  between  the  two  eyes.  On 
the  thirty-third  day  I  again  found  both  discs  slightly  hazy,  the 
right  being  less  well  defined  than  at  the  last  examination,  but  the 
left  less  obscured,  so  that  their  condition  was  now  practically  the 
same.  On  the  thirty-ninth  day  both  discs  were  quite  clear  and 
healthy.  On  the  forty-fourth  day  Dr.  Little  again  reported, 
"  Both  optic  nerves  quite  healthy  and  alike,  well  defined,  and 
no  haziness  whatever."  Hereafter  I  made  no  examination  until 
the  day  before  death,  when  I  was  unable  to  detect  any  departure 
from  the  normal,  but  when,  owing  to  the  patient's  condition  and 
restlessness,  it  was  difficult  to  make  a  satisfactory  examination. 

From  the  above  facts  it  will  appear  that  in  four  cases  of  crush 
of  the  upper  portion  of  the  spinal  cord  (third  cervical  to  second 
dorsal),  where  frequent  examinations  were  made,  ophthalmoscopic 
changes  were  found  in  three,  being  absent  in  one  only  ;  that  in 
three  other  cases  such  changes  were  absent  on  the  fiirst,  sixth, 
and  seventeenth  days  respectively ;  and  that  in  six  cases  which 
survived  the  accident  for  long  periods  no  subjective  symptoms 
arose,  so  that  optic  atrophy  probably  never  ensued. 

In  the  three  cases  known  to  be  affected  the  changes  consisted  in 
haziness,  with  want  of  definition  of  the  disc,  accompanied  by  slight 
distension  of  the  retinal  veins.  In  the  first  case,  the  changes 
ensued  on  the  fourth  or  fifth  day  after  the  accident;  they  in- 
creased until  the  sixth  day,  but  were  not  investigated  at  a  later 
period.  In  the  second  case,  they  had  commenced  on  the  third 
day,  increased  on  the  fifth,  and  been  followed  by  effusion,  ob- 
scuring the  smaller  vessels,  before  the  ninth,  aftei'  which  death 
prevented  further  change.  In  the  third  case,  the  haziness  and 
congestion  wei*e  found  on  the  sixteenth  day,  but  may  have  been 
present  previously ;  the  right  eye  almost  immediately  afterwards 
returned  to  the  normal  condition,  the  left  getting  worse ;  then 
the  left  improved,  and  the  right  again  presented  congestive 
changes  ;  and  finally,  on  the  thirty-ninth  day,  both  were  normal. 
In  all  the  cases  there  was  evidence  of  paralysis  of  the  cervical 
sympathetic ;  in  the  last,  remarkable  vascular  and  secretory 
changes  occurred  both  in  the  face  and  upper  limbs,  and  consecu- 
tive myelitis  first  got  worse,  and  then  again  improved.  In  none 
was  there  any  evidence  of  basic  cerebral  meningitis. 

So  far  as  I  can  ascertain,  the  occurrence  of  similar  changes  in 
the  optic  disc  in  cases  of  spinal  injury  has  not  hitherto  been 
described,  but  on  the  other  hand  there  are  no  complete  observa- 
tions which  would  indicate  a  negative  view.     True,  Dr.  Clifford 


OPHTHALMOSCOPIC   CHANGES.  I  77 

AUbutt  ^  states  that  in  seventeen  "  severe  injuries,  which  proved 
fatal  within  a  few  weeks,"  no  changes  appeared  in  the  eye,  and 
that  such  "  changes  do  not  become  established  in  the  cases 
which  run  a  short  course,  but  they  slowly  supervene  in  the  course 
of  weeks  or  months  in  more  chronic  cases."  We  are,  however, 
not  told  how  often  or  at  what  intervals  these  fatal  cases  were 
examined,  and  enough  has  been  said  to  show  that,  without  fre- 
quent observations,  the  changes  might  readily  be  overlooked.  On 
the  other  hand,  the  description  given  by  Dr.  Allbutt  of  certain 
effects  which  he  observed  in  "  chronic "  cases  of  spinal  injury 
coincides  almost  exactly  with  the  appearances  above  referred  to ; 
and  in  similar  accord  with  his  statement,  that  (always  in  chronic 
cases)  these  changes  are  the  more  readily  produced  the  higher  is 
the  lesion,  is  my  observation  of  three  (acute)  cases  in  the  cervical 
region  and  of  none  at  a  lower  level.  These  coincidences  are  the 
more  remarkable  because,  as  will  shortly  appear.  Dr.  Allbutt  has 
found  these  appearances  only  in  chronic  cases,  whereas  I  have 
failed  to  detect  them  except  in  severe  or  "  acute  "  spinal  injuries. 

II. — Slight  Spinal  Injuries  Unaccompanied  by  Direct 
Lesion  of  the  Cord  ok  by  Functional  Neuroses. 

Slight  blows,  bruises,  and  sprains  of  the  back  are  exceedingly 
common.  They  may  present  only  local  symptoms  (pain,  &c.),  or 
they  may  be  accompanied  by  a  sort  of  "  pseudo-paralysis,"  in 
which,  owing  to  the  fear  of  pain,  the  patient  avoids  free  move- 
ments of  the  limbs  or  spine,  holds  the  back  and  other  joints  rigid, 
and  perhaps  does  not  even  defaecate  or  urinate  with  his  normal 
force.  Cases  of  the  latter  description  are  fully  discussed  in  the 
third  chapter  of  Mr.  Page's  work  on  "  Injuries  of  the  Spine,"  ^ 
and  it  is  unnecessary  to  explain  more  fully  the  kind  of  injury  to 
which  reference  is  now  made.  But  in  spite  of  the  large  number 
of  such  minor  injuries  to  the  back  that  come  under  observation 
annually  in  hospital  practice,  I  have  found  none  in  which  there 
were  subjective  eye-symptoms,  nor  have  a  considerable  number 
of  ophthalmoscopic  observations  revealed  a  single  instance  of  any 
affection  of  the  optic  discs.  Moreover,  I  find  only  one  reported 
case  of  the  kind  in  which  such  changes  were  said  to  have  ensued, 
viz.,  that  of  Dr.  Thorowgood.^    The  patient  was  a  girl  twelve  years 

^  The  Ophthalmoscope  in  Diseases  of  the  Nervous  System,  &c.,  London,  187 1, 
also  Lancet,  January  15,  1870. 

2  Second  edit.,  London,  1885,  p.  120. 

^  Transactions  of  the  Clinical  Society  of  London,  vol.  viii.,  1875,  P-  ^• 

M 


IjiS  SURGERY   OF   THE   SPINAL   CORD. 

of  age,  who  received  a  blow — apparently  not  a  severe  one — on  the 
lower  part  of  the  back.  The  pain  which  was  thereby  caused  soon 
disappeared,  but  shortly  aft-erwards  she  had  pains  at  the  back  of 
the  neck,  with  tenderness,  slight  swelling,  and  muscular  stiffness ; 
this  also  got  better  in  a  few  days.  Then,  a  month  after  the 
accident,  she  rapidly  lost  the  sight  of  both  eyes  and  was  found 
to  have  the  condition  of  "  choked  discs."  The  latter  again  reco- 
vered in  about  a  month,  leaving  the  girl  in  perfect  health.  These 
changes  are  attributed  to  "  slowly  progressing  basic  meningitis" 
involving  the  optic  nerves ;  but  I  fail  to  appreciate  the  grounds 
for  such  a  diagnosis,  especially  as  the  ophthalmoscopic  appearances 
are  quite  different  from  those  found  by  any  other  observer  after 
spinal  injury,  and  I  can  only  regard  as  a  pure  accident  the  super- 
vention of  uncomplicated  acute  optic  neuritis  a  month  after  a 
blow  on  the  lower  part  of  the  back. 

In  certain  cases,  however,  slight  injuries  of  the  spine  may  be 
followed  by  a  subacute  or  chronic  spinal  meningitis,  but  such 
cases  are  unquestionably  uncommon,  only  two  having  come  under 
my  own  observation  among  some  four  hundred  railway  accidents 
and  spinal  injuries  due  to  various  causes.  Again,  chronic  dege- 
neration of  the  cord  is  said  occasionally  to  follow  the  slighter 
spinal  injuries,  but  this  also  must  be  a  rare  condition,  and  it  is 
one  which  I  have  not  personally  met  with. 

If,  however,  there  be  produced,  as  the  result  of  an  injury,  either 
chronic  meningitis  or  chronic  degeneration  of  the  spinal  cord, 
may  we  meet  with  ophthalmoscopic  changes  ?  Dr.  Clifford  All- 
butt  states  that  he  found  such  changes  in  eight  out  of  thirteen 
cases  which  he  examined ;  but  unfortunately  he  does  not  describe 
the  cases,  and  it  is  perhaps  permissible  to  doubt  whether  they 
were  all  genuine  spinal  injuries.  His  paper  appeared  in  1870, 
at  which  time  "  traumatic  hysteria"  was  hardly  known  and  trau- 
matic neurasthenia  hardly  recognised,  all  obscure  effects  of  injury 
to  the  nervous  system  being  called  injuries  of  the  spine.  Verriest  ^ 
also  records  a  case,  which  appears  to  have  been  an  instance  of 
chronic  traumatic  myelitis,  and  in  which  optic  neuritis  resulted. 
But,  with  these  exceptions,  we  have  no  reported  cases  of  secondary 
traumatic  spinal  disease  giving  rise  to  optic  neuritis,  the  obser- 
vations of  Mr.  Wharton  Jones  being,  as  we  shall  shortly  see, 
described  too  vaguely  to  constitute  reliable  data. 

Hence,  then,  we  may  perhaps  sum  up  this  section  of  the  sub- 
ject thus : — Slight  spinal  injuries  are  very  common,  but  there  is 
no  evidence  that  they  tend  to  be  followed  by  changes  in  the 

*  Page,  Brain,  1886,  voL  ix.  p.  262. 


OPHTHALMOSCOPIC   CHANGES.  I  79 

optic  disc.  Such  injuries  are,  however,  in  rare  cases  followed  by 
chronic  meningitis  or  myelitis,  and  in  the  latter  condition  there 
is  an  d  priori  probability  that  optic  neuritis  may  supervene.  Both 
of  these  affections  are,  however,  very  rare,  and  with  the  exception 
of  Dr.  Allbutt's  eight  cases,  in  which  we  have  not  the  materials 
for  an  accurate  diagnosis,  there  is  but  one  recorded  instance  of 
this  conjunction. 


III. — Traumatic  Neuroses,  with  or  without  Slight 
Injury  to  the  Spine. 

Under  the  above  heading  are  included  those  cases,  best 
illustrated  by  the  results  of  railway  collisions,  in  which,  although 
there  may  have  been  some  slight  sprain  of  the  spine,  the  result- 
ing symptoms  are  due  mainly  to  a  traumatic  neurosis.  The  cases 
differ  from  those  of  the  last  section  in  the  presence  of  this  latter 
most  important  factor,  and  the  distinction  between  the  two 
groups  is  of  the  greater  consequence,  as  it  is  not  impossible  that 
it  is  to  the  neurosis,  rather  than  to  the  spinal  injury,  that  we  owe 
such  changes  in  the  fundus  as  are  sometimes  met  with.  Here  also, 
however,  changes  of  the  optic  disc  are  so  rare,  that,  among  the 
numerous  railway  injuries  which  have  come  under  my  own  observa- 
tion, and  which  include  many  severe  cases  of  traumatic  neurosis, 
I  have  seen  but  one  doubtful  case  of  lesion  of  the  optic  disc — a 
case  which  will  be  more  fully  referred  to  below.  The  functional 
eye-symptoms,  to  which  reference  was  made  at  the  beginning  of 
this  chapter,  are  more  often  present  than  absent,  but  in  no 
instance  have  I  seen  them  followed  or  accompanied  by  organic 
changes.  For  obvious  reasons,  I  do  not  always  make  an  ophthal- 
moscopic examination  in  such  cases,  unless  there  is  some  sugges- 
tion of  eye-mischief ;  but  we  may  safely  assume  that  had  many 
of  those  which  were  not  thus  examined  presented  any  pathological 
change,  the  attention  of  the  railway  company  concerned  would 
probably  have  been  attracted  to  the  matter  in  at  least  one  instance. 

My  experience  is  therefore  directly  opposed  to  the  teaching  of 
most  writers,  who  appear  to  regard  optic  neuritis  as  a  frequent 
result  of  "  concussion  of  the  spine ;"  but  the  discrepancy  is  sus 
ceptible  of  explanation.  In  1869  Mr.  Wharton  Jones  ^  first 
stated  that  he  found  ophthalmoscopic  changes  in  certain  traumatic 
cases,  but  he  gave  no  details,  and  no  account  of  the  cases  in 
which  the  changes  were  found,  nor  of  the  frequency  with  which 

^  Failure  of  Sight  from  Railway  and  other  Injuries.     London,  1869. 


I  So  SURGERY   OF   THE   SPINAL   CORD. 

he  had  observed  them.  One  year  later  Dr.  Clifford  Allbutt  ^ 
published  the  observations  already  referred  to.  In  1 875  appeared 
the  second  edition  of  Mr.  Erichsen's  work  on  "  Concussion  of 
the  Spine."  Having  enumerated  the  various  subjective  symptoms 
already  referred  to,  he  gives  an  excellent  account  of  their  path- 
ology, and  then  passes  on  to  quote  largely  from  Mr.  Jones  and 
Dr.  Allbutt.  After  a  long  extract  from  the  latter,  he  says : 
"  One  or  other  of  these  conditions  occur  in  the  majority  of  cases 
of  spinal  injury,  such  as  we  are  describing  in  this  work,"  leaving 
on  the  mind  of  the  reader  the  impression  that  the  "  one  or  other 
of  these  conditions "  refers  to  the  different  ophthalmoscopic 
changes  observed  by  Dr.  Allbutt.  This  extraordinary  verbal 
confusion  has  since  been  repeated,  so  that  even  in  the  1884 
edition  of  his  text-book  (p.  778),  almost  the  same  words  are 
used,  and  the  reader  is  led  to  expect  optic  neuritis  in  almost 
every  case  of  "  spinal  injury  ; "  and  yet  Mr.  Erichsen  has  not 
mentioned  a  single  case  in  which  he  has  himself  seen  ophthal- 
moscopic changes.  In  their  respective  articles  on  spinal  injuries, 
Messrs.  Jacobson^  and  Liddell*  merely  quote  the  above  writers 
without  adding  any  evidence  of  their  own.  Dr.  Cowers*  also 
quotes  Dr.  Clifford  Allbutt,  without  brining  forward  any  fresh 
material.  And  thus  we  may  trace  back  to  the  same  source  the 
opinions  expressed  by  the  majority  of  writers  upon  this  point. 

Mr.  Page,^  on  the  other  hand,  who  has  investigated  the  subject 
for  himself,  arrives  at  conclusions  entirely  opposed  to  the  above, 
but  similar  to  mine,  saying  that,  in  this  class  of  cases,  he  has 
"  never  been  able  to  discover  any  lesion  or  pathological  change 
in  the  fundus  of  the  eye."  Similarly,  in  the  discussion  by  the 
Ophthalmological  Society  on  "  Eye-Symptoms  in  Diseases  of  the 
Spinal  Cord,"  ^  there  is  but  one  reference  to  injuries,  that  of  Dr. 
Hughlings  Jackson  (p.  229),  who  says  "he  knew  of  none  [i.e., 
of  no  eye-symptoms]  from  lesion  of  it  [the  cord],  excepting  when 
that  lesion  was  in  the  cilio-spinal  region  .  .  .  (contraction  of 
the  pupil  .   .   .  narrowing  of  the  ocular  aperture)." 

There  are,  however,  a  few  reported  cases,  of  which  I  believe 
the  following  to  be  a  complete  list,  in  which  optic  neuritis  has 

'  Loc.  cit. 

'  Holmes'  System  of  Surgery,  3rd  edit.,  London,  1883,  vol.  i.  pp.  656  and  703. 

'  Ashhurst's  Encyclopaedia  of  Surgery,  London,  1884,  vol.  iv.  p.  886. 

*  Medical  Ophthalmoscopy,  2nd  edit.,  London,  1882,  p.  169. 

'  Loc.  sup.  cit.      Also  Heath's  Dictionary   of  Surgerj',    article,   "  Disorders   of 
Vision  from  Injuries  of  the  Head  and  Spine." 

*  Trans.  Ophth.  Society,  vol.  iii.,   1883,  p.  190.     See  also  Gowers,  Lancet,  18S3, 
vol.  i.  pp.  869  and  1031,  and  Medical  Times  and  Gazette,  1883,  vol.  i.  p.  661. 


OPHTHALMOSCOPIC    CHANGES.  I  Si 

supervened  upon  so-called  spinal  injuries,  but  in  which  probably 
the  spinal  cord  played  no  part  in  the  production  of  the  symptoms. 
;Mr.  Bruce  Clarke  ^  records  two  cases.  The  first  is  that  of  a  man 
who,  ha\ang  fallen  upon  some  bottles,  sustained  one  or  two  scalp 
wounds,  and  suffered  from  mental  confusion,  followed  by  general 
weakness  of  his  muscles,  most  marked  in  the  right  arm,  with 
tenderness  over  the  lower  cervical  region.  This  patient  pre- 
sented "  intense  hypersemia  of  both  optic  discs,"  but  no  swelling 
or  affection  of  the  retinal  vessels,  and  no  interference  with  sight. 
In  this  case  the  man  would  appear  to  have  been  suffering  from 
hysteria,  and  certainly  there  is  no  sufficient  evidence  of  injury  to 
the  spinal  cord :  he  "  evidently  endeavoured  to  make  himself  out 
as  bad  as  he  could,"  and  hence  "the  dynamometric  test  was 
fallacious."  The  visual  fields  were  apparently  not  tested.  The 
second  case  was  one  of  a  fall  upon  the  back  of  the  head,  followed 
by  certain  psychical  symptoms,  loss  of  power  and  sensation  in 
the  left  leg,  retention  of  urine,  and  slight  priapism.  On  the 
third  day  both  discs  were  hyperasmic.  This,  again,  is  not  obvi- 
ously the  result  of  injury  to  the  spinal  cord,  there  being  in 
the  psychical  symptoms  a  suspicious  indication  of  some  cerebral 
lesion. 

Oppenheim  ^  also  gives  two  cases,  the  first  apparently  purely 
functional,  and  certainly  due  to  blows  upon  the  head,  without  any 
sign  of  cord-lesion ;  the  second  presenting  symptoms  resembling 
those  of  general  paralysis  or  sclerosis  in  patches,  and  due  to 
blows  inflicted  in  a  railway  collision,  both  on  the  back  of  the 
head  and  on  the  lower  part  of  the  back.  In  the  first,  the 
left  disc  was  found,  fourteen  months  after  the  accident,  to  be 
pale  and  slightly  atrophic,  the  visual  field  being  restricted  for 
colours.  In  the  second,  there  was  atrophy  of  the  right  disc 
with  contracted  colour-field.  In  the  paper  from  which  these  cases 
are  quoted,  Oppenheim  lays  much  stress  upon  them  as  indicating 
an  organic  origin  of  the  symptoms  of  "  traumatic  neuroses;  "  but 
in  a  later  article  ^  he  says  he  has  not  since  seen  such  appearances 
— a  statement  of  the  more  importance  in  view  of  his  extensive 
experience  and  careful  research.  In  any  case,  as  has  been  said, 
the  presence  of  cord-mischief  is  not  proved,  and  the  unilateral 
character  of  the  symptoms  points  rather  to  a  cerebral  origin. 

^  Loc.  cit.,  Cases  I.  and  III. 

^  Archiv  fur  PsycJnatrie,  vol.  xvi.,  1885,  p.  ySo.  See  also  Scholer  and  Uhthoff, 
Beitrdge  zur  Pathologie  des  Sehnerven  und  dcr  Netzhaut  bei  Allgemeinerkrankungen. 
Berlin,  1884,  p.  46. 

^  Berliner  klinische  Wochenschrift,  1888,  February  27,  p.  170 


1 82  SURGERY   OF   THE   SPINAL   CORD. 

Finally,  Pliiger^  quotes  cases  from  Mooren,^  whose  original 
article  I  have  been  unable  to  obtain,  but  quotes  so  vaguely  that 
it  is  impossible  to  be  sure  to  what  conditions  the  latter  is  referring. 
The  passage  runs :  Optic  neuritis  is  found  "  further  in  concussion 
of  the  brain,  and  even  of  the  spinal  cord,  of  which  Mooren  ad- 
duces several  cases  "  (des  weiteren  bei  Erschiitterung  des  Gehirns 
und  sogar  des  RUckenmarks,  wofiir  Mooren  mehrere  Falle  aufiPiihrt). 

From  the  above  summary  we  are  led  to  the  conclusion  that 
the  occurrence  of  optic  neuritis  is  extremely  rare  in  the  cases 
formerly  described  as  concussion  of  the  spine,  and  that  even  when 
present,  there  is  no  indication  whatever  that  it  bears  any  rela- 
tionship to  a  lesion  of  the  spinal  cord. 

The  final  question  remains,  When  such  changes  do  supervene, 
may  they  not  be  the  result  of  the  functional  neurosis  rather  than 
of  the  usually  trivial  bruise  or  sprain  of  the  back,  which  is  gene- 
rally also  present  ? 

On  page  195  is  reported  a  typical  instance  of  hysterical  hemi- 
ansesthesia  in  a  woman — the  result  of  a  railway  accident.  Not 
long  before  one  of  my  visits  to  this  patient.  Dr.  Dyson,  of  Sheffield, 
and  Dr.  Jones,  of  Wath,  examined  her  eyes,  and,  in  the  words  of 
the  former,  found,  on  the  opposite  side  to  the  ansesthesia,  "  intense 
hypersemia  of  retina  and  disc,  the  lower  part  of  the  disc  especially 
being  swollen  (choked)  and  its  margin  ill-defined."  A  few  days 
later  I  was  unable  to  satisfy  myself  that  there  was  any  abnor- 
mality, and  Dr.  Jones  stated  that  the  changes  which  he  had  seen 
had  vanished.  Fifteen  months  later  Dr.  Jones  writes  me  that 
"  the  disc  is  paler  than  the  other,  and  in  the  lower  border  (in- 
verted image)  a  large  artery  is  distinctly  lessened  in  calibre." 
Although  I  was  thus  unable  to  verify  the  observation,  there  can  be 
no  doubt  but  that  vascular  changes  had  been  manifested  in  a  case 
in  which  there  was  never  any  suggestion  of  spinal  injury,  but  in 
which  the  whole  course  was  that  usually  seen  in  traumatic  hysteria  ; 
but  unfortunately  the  case  is  rendered  of  little  value,  as  illustrat- 
ing any  connection  between  the  general  condition  and  the  optic 
change,  by  the  fact  that  a  very  severe  bruise  had  been  received 
on  the  same  side  of  the  face  as  the  aSected  eye,  and  that  it  is 
thus  impossible  to  deny  the  existence  of  a  peripheral  injury. 

Vascular  changes  in  the  disc  and  retina  are,  however,  certainly 
not  incompatible  with  the  recognised  results  of  hysteria,  in  which 
we  frequently  find  vascular  changes  elsewhere,  and  we  have  also 
other  evidence   that   ophthalmoscopic  changes  may  occur  apart 

*  Archiv  fiir  Ophthalmologte,  1 878,  Bd.  xxiv.  Abth.  ii.  p.  178. 
'  Ojphthalmolof/.  Mittheilungen  aus  dcm  Jakre  1 873. 


OPHTHALMOSCOPIC   CHANGES.  1 83 

from  organic  disease  of  the  nervous  system.  In  the  discussion 
by  the  Ophthalmological  Society,  already  referred  to,  the  late  Dr. 
Mahomed,^  remarking  "  how  much  can  we  rely  on  such  symptoms 
as  localising  symptoms,  or  even  symptoms  of  organic,  as  distin- 
guished from  functional,  disease,"  refers  to  several  cases  of  optic 
atrophy  or  neuritis  "  in  association  with  various  conditions  of 
deteriorated  health,"  and  "  in  association  with  catamenial  irregu- 
larities ; "  and  finally,  reviewing  the  evidence,  he  says,  "  It  ap- 
pears to  me  that  they  may  be  produced  by  conditions  of  nervous 
exhaustion,  of  sympathetic  excitation,  by  reflex  trophic  disorders, 
and  other  remote  or  difi'used  conditions.  If  this  be  so,  it  is  clear 
that  we  should  never  pronounce  a  grave  diagnosis  on  the  evidence 
afforded  by  such  symptoms  as  these  alone.  .  .  .  They  may  mean 
functional  disorder,"  &c.  Other  writers  have  frequently  described 
optic  neuritis  in  hysteria  and  other  conditions  of  general  debility 
{cf.  Gowers,  "  Medical  Ophthalmoscopy,"  p.  175).  And  in  a 
very  complete  paper  on  "Functional  Eye-Symptoms  in  Hysteria 
and  Allied  Conditions,"  Dr.  Hill  Griffith  "  records,  among  four  cases 
of  "  hysterical  blindness,"  one  of  "  marked  hyperemia  of  discs," 
and  one,  in  which  "  the  retinal  vessels  are  tortuous  to  a  very 
marked  extent." 

On  these  grounds,  then,  it  would  appear  that  there  is  an  a 
priori  probability  that  the  functional  traumatic  neuroses  may  give 
rise  to  changes  in  the  optic  discs ;  that  there  is  some  evidence 
that  such  changes  have — although  very  rarely — been  observed ; 
and  that  in  this  way  we  may  perhaps  explain  some  of  the  cases 
in  which  the  appearances  were — in  the  absence  of  satisfactory 
evidence — attributed  to  a  lesion  of  the  spinal  cord. 

^  Loc.  cit.,  p.  246. 

*  Trans.  Oph.  Soc,  vol.  viii.,  1888. 


CHAPTER  VIII. 

TRAUMATIC   HYSTERIA,   ESPECIALLY  IN   RELATION 
TO   RAILWAY  ACCIDENTS. 

It  is  but  a  few  years  since  "  concussion  "  was  regarded  as  one  of 
the  commonest  injuries  of  the  spinal  cord,  and  the  exact  nature, 
and  especially  the  prognosis  of  that  disease,  has  perhaps  been 
productive  of  as  wide  differences  of  opinion  and  of  as  much 
discussion  as  any  question  in  pathology.  And  although  recent 
writers  are  now  practically  unanimous  in  agreeing  that  concus- 
sion of  the  spinal  cord  is  at  least  an  extremely  rare  lesion,  there 
is  still  much  dispute  as  to  the  significance  of  the  nervous  symp- 
toms commonly  observed  after  severe  physical,  or  physical  and 
psychical,  shocks.  Under  these  circumstances  it  will  perhaps  not 
be  out  of  place  to  collect  here  a  number  of  cases  which  have  come 
under  my  own  observation,  comparing  with  current  doctrines  the 
lessons  which  they  teach,  and  thus  presenting  a  rdsuniS  of  our 
present  knowledge  of  a  pathological  condition  which,  although 
not  very  common,  is  by  no  means  rare,  as  the  result  of  railway 
collisions  and  other  severe  accidents.  In  thus  sketching  the 
clinical  history  of  traumatic  hysteria,  I  do  not  claim  to  be 
bringing  forward  any  strictly  original  matter,  but  rather  to  be 
presenting  certain  facts  which  are  as  yet  but  imperfectly  familiar 
to  many  of  the  profession,  but  upon  which  we  may  at  any  time 
be  required  to  express  a  very  definite  judgment. 

I.  Definition. 

A  satisfactory  definition  of  the  term  "  traumatic  hysteria  "  is 
hardly  possible,  but  a  fairly  clear  conception  of  the  meaning  in 
which  it  is  here  used  may  be  obtained  by  a  series  of  negations. 
An  injury  may  act  upon  the  nervous  system  in  one  of  several 
ways.     We  may  have  a  direct  mechanical  solution  of  continuity. 


TRAUMATIC   HYSTERIA.  1 85 

a  haemorrhage,  inflammatory  changes  (acute  or  chronic),  or  other 
organic  (degenerative)  processes.  There  are  also  certain  trau- 
matic effects  of  which  the  pathology  is  as  yet  obscure — probably 
ichortemic — as  hydrophobia  and  tetanus.  In  other  cases,  injury 
merely  calls  forth  manifestations  of  a  more  or  less  latent  patholo- 
gical condition,  as  in  post-traumatic  delirium  tremens.  All  of 
these  can  be  at  once  excluded  from  consideration.  Again,  local 
injury  to  a  nerve  may  give  rise  to  phenomena  known  as  reflex,  a 
term  including  another  obscure  group  of  cases,  susceptible  pro- 
bably of  a  more  refined  division.  Where  there  is  a  distinct  reflex 
effect,  or  where  the  injured  nerve  is  certainly  the  source  of  a  pro- 
gressive organic  change,  we  can  again  exclude  the  cases  from 
consideration,  but  some  instances  described  as  "  reflex  paralysis  " 
fall,  I  believe,  within  the  category  of  traumatic  hysteria. 

There  remain  a  large  number  of  nervous  affections,  of  traumatic 
origin,  not  known  to  possess  any  organic  basis,  and  with  somewhat 
ill-defined  outlines,  among  which  we  must  seek  for  the  cases  now 
under  consideration, — affections  described  as  "  shock,"  "  concus- 
sion," "  neurasthenia,"  and  "  hysteria."  "  Shock  "  is  an  expression 
of  a  comparatively  definite  and  well-recognised  meaning,  which  it 
is  not  necessary  now  to  discuss  at  length,  but  which  does  not 
include  hysteria.  "  Concussion,"  on  the  other  hand,  is  used  in 
the  vaguest  possible  manner,  in  the  nosology  of  some  writers 
apparently  covering  nearly  all,  if  not  all,  the  functional  as  well  as 
some  of  the  organic  traumatic  nervous  lesions.  The  classical 
"  concussion  of  the  brain "  is  a  well-understood  affection,  repre- 
senting almost  certainly  a  definite  organic  pathology,  viz.,  intra- 
cerebral hasmorrhages.  To  such  cases  it  should,  I  believe,  be 
restricted  for  the  present,  as  its  otherwise  vague  signification 
only  obscures  our  views  of  many  affections  capable  of  much  more 
accurate  description. 

"  Neurasthenia  "  is  constantly  spoken  of  by  English  writers  as 
almost  synonymous  with  hysteria,  from  which,  however,  it  can  and 
should  be  clearly  distinguished.  The  symptoms  of  neurasthenia 
arise  from  a  general  defect  in  the  nutrition  and  action  of  the 
nervous  system,  and,  when  they  follow  an  injury,  are  characterised 
chiefly  by  general  debility,  confusion  of  thought,  loss  of  memory, 
mental  irritability,  disturbed  sleep,  dreaming,  headache  (usually 
posterior),  interference  with  visual  accommodation,  photophobia, 
palpitation,  frequency  of  the  pulse,  dyspeptic  troubles  (furred 
tongue,  foul  breath,  constipation,  and  nausea  or  epigastric  pain), 
sweating,  a  concentrated  condition  of  the  urine,  &c.  This  is  a 
clinical  picture  which,  with  slight  variations,  constantly  presents 


1 86  SURGERY   OF   THE   SPINAL   CORD. 

itself  after  injuries,  especially  after  railway  injuries.  The  symp- 
toms follow  those  of  "  shock,"  and  are  the  expression  of  an 
exhausted  nervous  system.  They  are  generally  transient,  and 
will  pass  away  under  conditions  and  a  line  of  treatment  which 
may  be  briefly  described  as  "  tonic." 

That  such  neurasthenia  may  be,  and,  indeed,  frequently  is, 
combined  with  true  traumatic  hysteria,  cannot  be  denied ;  but 
the  two  conditions  are  nevertheless  essentially  distinct,  and,  even 
when  they  are  present  together,  the  symptoms  pertaining  to  each  can 
generally  be  clearly  separated.  Neurasthenia  is  far  more  common 
than  hysteria  (out  of  some  three  hundred  cases  of  railway  accident, 
of  which  I  have  notes,  I  find  only  about  twenty-five  of  hysteria, 
whereas  more  or  less  neurasthenia  is  almost  invariable)  ;  its  effects 
are  much  more  diffused  throughout  the  system,  and  less  well 
defined ;  and  its  duration  is  usually  comparatively  brief.  It  may 
be  said  that  the  one  is  merely  a  minor  degree  of  the  other,  but  I 
doubt  if  this  be  pathologically  true,^  and  for  practical  purposes  we 
can  certainly  draw  a  rough  distinction. 

Granting,  then,  that  sharp  divisions  are  at  present  impossible, 
I,  nevertheless,  think  that  we  may  tentatively  classify  the  post- 
traumatic functional  neuroses  somewhat  as  follows : — 

1.  Acute  effects. 

(a.)  General  nervous  depression — "  shock  "  or  "  collapse." 
(5.)  A  more  localised  and  defined  disturbance  of  cerebral 
(cortical)  origin — "  acute  hysteria  "  or  "  hysterics." 

2.  Chronic  after-effects. 

(a.)  General  nervous  depression — "  neurasthenia." 
(J.)  A  more  localised  and  defined  disturbance   of  cerebral 
(cortical)  origin — "  chi'onic  hysteria." 

Such  an  arrangement,  even  if  it  be  somewhat  arbitrary,  is  at 
least  convenient  for  purposes  of  reference  and  of  description,  and  it 
has  the  advantage  of  avoiding  the  coining  of  new  terms.  I  would, 
tlien,  endeavour  to  define  "  traumatic  hysteria "  as  a  functional 
affection  of  the  nervous  system,  resulting  from  an  injury,  due  pro- 
bably to  a  change  localised  in  some  portion  of  the  cerebral  cor- 
tex, and  manifested  by  correspondingly  well-defined  and  localised 

^  If  the  pathogeny  of  hysteria  be  "suggestion  "  or  "auto-suggestion,"  and  that  of 
neurasthenia  merely  exhaustion,  there  is  a  clear  theoretical  as  well  as  a  practical 
distinction. 


TRAUMATIC    HYSTERIA.  1 87 

symptoms.  Or  we  may  say  that  it  lias  no  known  organic  basis, 
that  it  is  not  reflex  in  origin,  and  that  it  is  neither  shock  nor 
neurasthenia.^ 


2.  History  and  Nomenclature. 

Traumatic  hysteria  has  been  studied  chiefly  from  two  points 
of  view ;  two  series  of  observations  having  originated  apart 
and  gradually  converged.  Thus  we  have,  on  the  one  hand,  the 
recent  growth  of  our  knowledge  concerning  hysteria ;  on  the 
other,  we  have  the  writings  of  those  who  have  been  interested 
in  the  real  or  supposed  peculiarities  presented  by  railway 
accidents. 

Hysteria  has,  of  course,  been  recognised  for  ages,  but  has, 
until  comparatively  recently,  been  regarded  as  an  affection  pecu- 
liar to  the  female  sex  and  connected  with  the  generative  organs. 
The  latter  idea  is  now  entirely  abandoned,  and  of  late  years  it 
has  been  amply  demonstrated,  especially  by  Charcot  and  his 
pupils,  that  the  male  sex  is  liable  to  neuroses  which,  owing  to 
the  similarity  of  their  manifestations  to  those  of  female  hysteria, 
have  naturally  received  the  same  name.  It  is  hence  universally 
accepted  that,  although  much  commoner  in  the  female  sex,  and 
perhaps  not  unfrequently  finding  their  origin  in  diseased  con- 
ditions of  the  genital  organs,  the  symptoms  thus  designated  are 
essentially  of  nervous  origin,  and  may  be  induced  by  very  various 
causes,  the  action  of  which  is  not  limited  to  the  female.  Hence 
we  are  now  all  perfectly  familiar  with  "  hysteria  in  the  male," 
and  have  ceased  to  feel  surprise  at  the  paradox  implied  in  the 
use  of  this  etymologically  meaningless  term. 

Another  line  of  investigation  has  familiarised  us  with  im- 
portant local  manifestations  of  hysteria,  which  have  received 
prominence  only  within  the  last  half-century.  Brodie  (^)  *  first 
drew  attention  to  certain  joint-affections,  dependent  apparently  on 
a  functional  change  in  the  nervous  system,  and  so  closely  allied 
to  the  before-known  manifestations  of  hysteria  as  to  have  been 
placed  within  the  same  category.     Coulson,(^)  Skey,(^)  and  others 

^  It  may  be  well  here  to  point  out  that,  in  addition  to  the  troubles  above  referred 
to,  accidents  may  be  followed  by  other  symptoms,  which,  regarded  superficially,  would 
appear  to  indicate  a  lesion  (organic  or  functional)  of  the  nervous  system,  but  which 
are  really  due  solely  to  an  endeavour  to  prevent  pain,  as  from  a  sprain,  &c.  Mr. 
Page  has  described  at  length  how  many  cases  of  so-called  "concussion"  are  but 
sprains  of  the  spine,  with  concomitant  muscular  rigidity  or  feebleness,  arising  from 
purely  local  causes. 

*  The  numbers  refer  to  the  Bibliography  appended  to  this  chapter. 


105  SUKGERY   OF   THE   SPINAL    COED. 

insisted  upon  and  extended  Brodie's  conclusions.  It  is,  however, 
mainly  to  Russell  Ileynolds,(*^)  followed  by  the  French  school, 
with  Charcot,  {^^'  ^^■)  at  its  head,  that  we  owe  our  present  detailed 
knowledge  of  the  phenomena  of  this  pathological  state. 

The  knowledge,  or,  at  any  rate,  the  due  recognition  of  injury 
as  a  cause  of  hysteria,  would  appear  to  have  arisen  entirely 
within  this  same  half-century.  Suggested,  but  without  emphasis, 
by  the  earlier  writers  above  quoted,  the  connection  has  been  mainly 
insisted  upon  by  the  French  school,  by.Wilks  (^^)  and  Page  (^*)  in 
this  country,  and  by  Walton  (^^'  ^^)  and  Putnam  (^^)  in  America. 
That,  in  either  sex,  symptoms  resembling  those  of  hysteria  may 
arise  from  injury  is  now  placed  beyond  all  doubt,  and  it  is  equally 
certain  that  many  cases  formerly  differently  described  belong  to 
the  same  group.  Such  cases  may  be  found  in  the  writings  of 
Larrey,(^)  Weir  Mitchell,(^)  Erichsen,(^^)Brown-Sequard,(-^)Oppen- 
heim,(^^'  ^^)  &c.  Such  is  a  brief  outline  of  the  history  of  our 
knowledge  of  traumatic  hysteria,  as  observed  in  military  surgery 
and  in  the  ordinary  accidents  of  civil  life. 

Running  side  by  side  with  the  gradual  growth  of  the  con- 
clusions thus  referred  to,  there  has  been  a  controversy  which 
frequently  trenches  upon  the  same  ground — the  discussion  of  the 
significance  of  the  symptoms  observed  mainly  in  the  victims  of 
railway  collisions. 

Mr.  Erichsen,(^^)  in  a  work  which,  for  careful  observation  and 
graphic  description,  is  probably  unsurpassed  in  our  language,  has 
enumerated  the  majority  of  these  symptoms,  attributing  them  to 
a  change  in  or  about  the  spinal  cord,  frequently  to  a  meningo- 
myelitis,  and  classifying  them  as  "  concussion  of  the  spine."  As 
the  result  of  the  views  so  ably  expressed  by  him,  we  have  the 
term  "  railway  spine  "  now  imported  into  various  European  lan- 
guages. The  most  obvious  difficulty  which  arose  in  the  way  of 
this  theory  was  the  fact  that  many,  if  not  all,  of  the  symptoms 
would  appear  to  be  of  cerebral  rather  than  of  spinal  origin,  and  Mr. 
Erichsen's  own  view  of  an  extension  of  meningo-myelitis  to  the 
cranial  contents  has  appeared  to  many  authors  to  be  unneces- 
sary, arbitrary,  and  unsupported  by  any  evidence.  Hence  Put- 
nam,(^«)  Walton,(i^)  Westphal,(i°)  Moeli,('')  Oppenheim,(^^)  and 
many  others,  have  looked  rather  to  the  brain  than  to  the  spinal 
cord  as  the  source  of  the  evil,  and  we  have  the  term  "  railway 
spine "  replaced  by  the  undoubtedly  preferable  "  railway  brain." 
Such  a  change  is,  however,  obviously  but  one  step  towards  the 
truth.  "  Railway  brain "  connotes  no  definite  pathology,  and, 
like  its  predecessor,  includes  many  diverse  conditions. 


TRAUMATIC    HYSTERIA.  I  89 

Hence  others,  as  Oppenlieim  in  his  later  works,  have  endea- 
voured to  express  the  facts  in  more  definite  and  more  intelligible 
terms.  Mr.  Page  (^*)  has  done  more  than  any  other  surgeon 
to  render  our  ideas  upon  this  point  somewhat  less  obscure,  and  he 
classifies  the  majority  of  bond  fide  neuroses  as  "  neurasthenia," 
as  almost  synonymous  with  which  he  uses  also  the  term  "  hys- 
teria." Modifying  this  view  very  slightly,  I  should  be  inclined, 
as  above  stated,  merely  to  limit  the  term  "  neurasthenia " 
rather  more  than  he  does,  and  to  distinguish  more  sharply 
between  that  affection  and  hysteria.  The  American  writers 
already  quoted  distinctly  admit  the  "  hysterical "  aspect  of  many 
cases.  Oppenheim,(^^)  clearly  recognising  the  cerebral  source  of 
these  various  troubles,  and  describing  the  symptoms  together, 
calls  them  "  traumatic  neuroses  "  or  "  traumatic  neuropsychoses." 
Strlimpell  ('^)  also  speaks  of  traumatic  neuroses,  which  he  divides 
into  "  general  traumatic  neuroses  "  and  "  local  traumatic  neuroses," 
the  former  subdivision  including  roughly  those  symptoms  to  which 
I  have  referred  as  neurasthenic,  together  with  some  of  the  hys- 
terical affections,  the  latter  those  of  hysteria  solely.  Bernhardt  ('^) 
recognises  three  classes  of  cases,  viz. :  ( i .)  those  in  which  there 
are  fairly  definite  symptoms,  probably  of  organic  origin  ;  (2.)  those 
of  hysteria  or  hystero-epilepsy  ;  and  (3.)  those  in  which,  without 
any  definite  symptoms,  there  is  a  feeling  of  weakness,  malaise, 
and  inability  to  work.  Cenas  ('^)  clearly  describes  as  the  possible 
results  of  a  railway  accident  (l.)  meningo-myelitis  and  meningo- 
encephalitis, which  are  rare  ;  (2.)  hysteria ;  and  (3.)  neurasthenia. 
Hence,  then,  there  would  now  seem  to  be  a  fairly  general  accept- 
ance of  the  classification  which  has  been  used  above,  and  the 
term  "  traumatic  hysteria  "  is  very  widely  adopted  as  a  descrip- 
tion of  many  cases  of  functional  nerve-disease  arising  from  rail- 
way accidents.  I  would  only  repeat,  that,  in  my  opinion,  neura- 
sthenia and  hysteria  are  distinct,  and  that,  often  as  they  are 
found  in  combination,  neurasthenia  is  common  without  hysteria, 
and  hysteria  is  at  least  not  unknown  without  neurasthenic 
symptoms. 

A  few  words  are  required  with  reference  to  the  use  of  the  term 
"  traumatic  hysteria."  I  employ  it  because  it  appears  to  me 
highly  inadvisable  to  replace  old  names  by  newly-coined  ones, 
unless  the  former  be  distinctly  objectionable.  Hysteria  is,  by 
some,  regarded  as  inadmissible,  on  account  of  its  etymology,  its 
original  significance,  and  the  erroneous  theory  which  it  implied. 
But  we  have  now  finally  escaped  from  all  danger  of  being  misled 
by  the  older  views.     Hysteria  no  longer  connotes  any  theory,  and, 


igO  SURCJERY    OF   THE   SPINAL   CORD. 

in  the  present  imperfect  state  of  pathological  science,  it  is  often 
better  to  use  meaningless  words  rather  than  such  as  imply  a 
theory  which  may  turn  out  to  be  wrong.  Extremes  here  meet, 
and  a  word  which  means  nothing,  or  a  word  which  refers  to  an 
utterly  dead  theory,  are  equally  useful.  Typhoid  is  no  longer 
confused  with  typhus,  smallpox  conveys  no  suggestion  of  a  rela- 
tionship to  syphilis,  rachitis  does  not  for  us  mean  inflammation  of 
the  spine,  and  hysteria  does  not  mean  a  reflex  utero-ovarian  neu- 
rosis. Why  uproot  a  term  whose  significance  is  intelligible  to 
all,  and  which  can  never  again  mislead,  as  possibly  some  of  its 
proposed  substitutes  may  do  ? 


3.  Etiology. 

Certain  predisposing  elements  in  the  causation  of  traumatic 
hysteria  have  to  be  considered : — 

(i.)  Age. — Like  all  hysteria,  the  traumatic  form  is  an  affection 
chiefly  of  middle  life.  Berbez  (^^)  found  the  average  age  of  twenty- 
one  cases  to  be  twenty-five  years;  the  youngest  being  19,  and 
the  oldest  $6.  Of  seventeen  cases  which  have  come  under  my 
own  notice,  the  average  age  was  31  ;  being  in  the  female  28^, 
and  in  the  male  35  ;  the  youngest  was  a  girl  aged  18,  the  oldest 
a  man  aged  42. 

(2.)  Sex. — It  is  hardly  necessary  to  repeat  that  the  male  sex 
is  by  no  means  exempt.  Indeed,  Berbez  concluded  that  traumatic 
hysteria  was  commoner  in  men  than  in  women,  having  seen  four- 
teen cases  in  the  former  and  seven  in  the  latter.  His  statistics, 
however,  take  no  account  of  the  fact  that  accidents  are  much 
commoner  among  men.  I  find  that  of  228  persons  injured  in 
railway  accidents,  157  were  males  and  7 1  females,  and  that 
among  the  former  there  were  ten,  and  among  the  latter  thirteen 
cases  of  distinct  "  chronic  "  hysteria.  This  comparison  yields  a 
percentage  of  6.37  for  men  and  of  i  8.3  i  for  women ;  or  roughly, 
the  probabilities  of  a  railway  accident  being  followed  by  hysteria 
is  three  times  as  great  in  the  female  as  in  the  male. 

(3.)  Marriage  appears  to  have  no  influence. 

(4.)  Heredity. — The  evidence  is  here  most  conflicting.  Some 
writers — mostly  those  of  the  French  school  ^ — maintain  that  there 
is  always,  or  nearly  always,  a  hereditary  taint ;  others,  chiefly 
among  the  German  writers,  find  no  grounds  to  suppose  that  heredity 
has  any  influence — a  view  more  in  accord  with  my  own  expe- 

^  Cf.  Berbez  (p.  15),  who  found  a  hereditary  taint  in  nine  out  of  twenty-one  cases. 


TRAUMATIC   HYSTERIA.  I9I 

rience,  which  appears  to  show  that  the  effect  of  hereditary  neu- 
rotic antecedents  has  been  much  exaggerated. 

(5.)  Race. — The  evidence  of  the  SaliMriere  Clinique  is  that 
race  has  no  effect,  but  the  experience  of  British  observers  tends 
to  show  that  hysteria  is  a  more  serious  affection  in  France  than 
it  is  with  us.      {Cf.  British  Medical  Journal  Q^).) 

(6.)  Occupation  and  social  circumstances  would  appear  to  be 
without  influence. 

(7.)  A  "  neurotic  temperament "  almost  certainly  plays  some 
part  in  the  production  of  traumatic  hysteria,  although  it  has  here 
nothing  like  the  importance  which  it  possesses  in  relation  to 
ordinary  hysteria. 

(8.)  Chronic  alcoholism  probably  predisposes  to  traumatic  hys- 
teria, as  to  hysteria  in  general. 

The  exciting  cause  is  of  course  an  accident,  but  the  varying 
conditions  of  the  accident  are  of  etiological  importance.  There 
can  be  no  question  but  that  mental  impressions  are  of  far  greater 
effect  in  the  production  of  traumatic  hysteria  than  is  physical  injury. 
Hence  horrible  surroundings,  as  where  several  people  are  injured 
at  the  same  time,  will  increase  the  risk  of  its  production.  Two 
somewhat  opposed  conditions  will  also  do  so,  viz.,  extreme  sudden- 
ness, on  the  one  hand,  or  a  period  of  terror  immediately  preceding 
the  accident,  on  the  other.  The  effect  of  terrible  surroundings  and 
suddenness  is  one  cause  of  the  disproportionately  large  number  of 
hysterical  cases  after  railway  collisions,  and  perhaps  in  military  sur- 
gery.^ Case  5  3  is  a  good  instance  of  previous  terror.  The  subjective 
element  in  the  etiology  is  well  illustrated  by  Case  56.  This  woman 
was  in  a  railway  accident,  in  which,  owing  to  the  breaking  of  an 
axle,  a  carriage  was  overturned  and  cut  to  pieces  by  a  train  on  the 
opposite  line.  Everybody  in  the  damaged  carriage  was  hurt,  and 
four  persons  were  killed,  but  the  shock  was  hardly  felt  at  all  by 
the  passengers  in  the  rest  of  the  train,  of  whom  our  patient  was 
one,  and,  with  the  exception  referred  to,  none  of  whom  complained 
of  the  slightest  injury.  Per  contra,  it  is  a  frequent  observation 
that  children  or  persons  who  have  been  asleep  or  drunk  at  the 
time  of  a  railway  accident  suffer  less  than  others  from  the  effects 
of  "  nervous  shock." 

Direct  injury  to  a  nerve  would  also  seem  to  be  a  potent  cause 
of  hysteria,  and  many  cases  described  as  "  reflex "  undoubtedly 
belong  to  this  category.^  In  Case  62,  in  which  the  hysterical 
symptoms  came  on  much  later  than  usual,  the  previous  nerve-lesion 

iLarrey(i).     Weir  Mitchell  (8). 

»  Brown-S^quard  ("i).     Weir  Mitchell  (8). 


192  SURGERY   OF   THE   SPINAL   CORD. 

may  have  supplied  the  requisite  stimulus,  and  I  have  recently 
seen  a  case  in  which,  in  a  very  slight  railway  collision,  the  patient 
received  a  contusion  of  the  right  ulnar  nerve,  followed  by  total 
anaesthesia  in  its  distribution,  with  partial  hemi-anaesthesia,  retrac- 
tion of  the  field  of  vision,  and  dragging  of  the  foot  upon  the  same 
side. 

It  is  to  be  remembered  that  the  severity  of  the  injury — that  is, 
the  mechanical  severity — bears  no  relation  whatever  to  the  liability 
to  hysteria.  On  the  other  hand,  the  region  injured  certainly 
appears  to  affect  the  result.  Numerous  reported  cases  show 
clearly  that  head-injuries  are  liable  to  cause  complete  hemi- 
ansesthesia  or  double  monoplegia,  the  symptoms  arising  on  the 
same  side  as  the  lesion.  {Cf.  Case  53,)  Also  injuries  in  the 
region  of  joints  appear  to  have  some  special  tendency  to  produce 
localised  functional  neuroses — the  shoulder  being  especially  ex- 
posed to  such  effects.     (Case  54.) 

Lastly,  it  must  not  be  forgotten  that  surgical  operations  are 
injuries,  and  that  hysterical  symptoms  after  operations  are  by  no 
means  rare.  To  this  cause  are  probably  to  be  attributed  some  of 
the  nervous  troubles  which  are  often  ascribed  to  the  anaesthetic, 
but  which  are  thus  more  likely  to  be  diminished  than  increased 
by  its  use. 

4.  Symptoms. 

The  symptoms  of  traumatic  hysteria  are  readily  divisible  into 
two  groups,  owning  a  possibly  quite  different  pathology.  We 
have,  firstly,  certain  manifestations  which  come  on  immediately 
after  the  accident,  and  last  for  a  very  short  period ;  and,  secondly, 
those  which,  whether  they  come  on  at  once  or  not,  are  of  much 
more  persistent  duration.  To  the  first  group  I  propose  now  to 
devote  but  a  passing  attention. 

(i.)  Acute  Hysteria. — It  is  a  matter  of  almost  daily  observa- 
tion that  injuries  may  give  rise  to  passing  "hysterical"  mani- 
festations— loud  screaming,  crying,  laughter,  or  even  convulsions. 
These  nervous  symptoms  are  explosive  in  nature,  and  generally  soon 
pass  away,  leaving  either  no  trace  of  their  presence  or  a  merely 
temporary  nervous  lassitude — a  slight  form  of  neurasthenia.  As 
suggested,  they  are  very  different  from  the  more  defined  and 
stable  forms  of  hysteria,  are  merely  a  manifestation  of  a  passing 
excitement,  and  have  little,  if  any,  connection  with  the  more 
serious  symptoms.     We  need  not  now  refer  to  them  further. 

There  is,  however,  another  aspect  of  "  acute  "  hysteria.     It  is 


TRAUMATIC   HYSTERIA.  1 93 

commonly  found  that  the  victims  of  railway  accidents  have  passed 
through  a  more  or  less  brief  stage  of  what  they  call  unconscious- 
ness. This  is  not  the  ordinary  unconsciousness  of  "  concussion  of 
the  brain ; "  and  it  is  unaccompanied  by  any  of  the  usual  symp- 
toms of  the  latter  condition — vomiting,  relaxation  of  the  sphincters, 
&c.  The  condition  is  rather  one  of  general  obliquity  to  external 
impressions,  in  which  many  voluntary  acts  are  performed  almost 
automatically,  the  higher  mental  faculties  alone  being  in  abeyance. 
Such  a  state  resembles  much  more  closely  the  hypnotic  condition. 
The  injured  person  may  get  up  and  walk  away,  taking  little  or 
no  notice  of  his  surroundings,  acting  as  in  a  dream,  and  perhaps 
only  "  coming  to  himself"  after  a  considerable  interval,  and  at 
some  distance  fx'om  the  scene  of  his  accident.  Many  of  the  per- 
sons injured  in  the  Hexthorpe  collision,  on  September  16,  1887, 
told  me  that  they  "  found  themselves  across  the  field  "  adjoining 
the  line  where  the  collision  occurred ;  others  that  they  walked  to 
Doncaster,  but  had  no  recollection  of  so  doing.  Vibert  (^^)  men- 
tions a  man  who  thus  proceeded  from  Charenton  to  Paris,  passing 
many  people  on  the  line,  but  totally  ignoring  them ;  and  another 
man,  inj  ured  in  a  collision,  who,  mechanically  as  it  were,  travelled 
by  rail  and  coach  for  an  entire  day  to  reach  his  home.  Such 
persons  have  a  remarkable  dazed  look,  which  is  admirably  repre- 
sented in  the  young  man  occupying  the  foreground  of  Mrs.  Butler's 
picture  "  Balaclava,"  The  whole  aspect  and  manner  are  strik- 
ingly similar  to  those  of  a  state  of  somnambulism.  Further,  such 
persons  often  have  extraordinary  after-impressions  of  the  accident. 
They  describe  something  very  large  overwhelming  them,  or  they 
think  they  remember  episodes  which  cauld  not  have  occurred. 
Many  passengers  in  the  trains  which  collided  at  Hexthorpe  gave 
circumstantial  accounts  of  the  actions  of  the  railway  servants 
or  of  themselves,  of  screams,  waving  of  hands,  seeing  signals 
moved,  attempting  to  get  out  of  the  carriages,  &c.,  details  totally 
incompatible  with  the  time  allowed  by  a  train  coming  suddenly 
round  a  corner  at  a  rate  of  twenty  miles  an  hour.  Here,  doubt- 
less, we  have  to  do  with  "  auto-suggestion,"  during  a  condition 
resembling  that  of  hypnotism.  One  of  the  most  remarkable 
accounts  thus  given  me  was  that  of  a  man  shaken  in  a  very 
slight  collision.  He  was  travelling  with  his  wife,  and,  after 
describing  how  he  himself  was  hurt,  he  told  me  that  the  latter 
fell  forwards  with  her  left  eye  on  to  the  point  of  an  umbrella,  held 
by  a  person  opposite  to  her ;  that  this  umbrella  struck  her  just 
above  the  eye  and  knocked  it  out  on  to  her  cheek ;  and  that  he 
then  placed  the  hollow  of  his  hand  over  her  eye  and  pushed  it 

N 


194  SURGERY   OP   THE    SPINAL   CORD. 

back !  This  statement  was  at  least  not  contradicted  by  the  wife, 
in  whose  presence  it  was  made  to  me.  When  I  saw  the  woman, 
the  eye  was  in  its  normal  position,  the  sight  was  perfect,  there 
had  never  been  any  cut  or  wound,  but  there  was  some  ecchymosis. 
That  the  man  believed  his  tale  I  have  little  doubt,  as  it  was  too 
ridiculous  for  a  fraud,  and  the  most  rational  explanation  seems  to 
be  that  this  was  a  hysterical  dream. 

I  may  refer  also  to  the  case  of  a  gentleman  well  known  in 
Manchester,  who,  while  travelling  with  me,  allowed  the  train,  in 
which  he  should  have  proceeded,  to  leave  a  side  station  without 
him.  Seeing  the  train  already  started,  he  ran  after  it,  attempted 
to  get  on,  and  fell  on  to  the  line,  sustaining  fortunately  no  serious 
injury.  He  afterwards  described  minutely  how  he  had  tried  to 
get  on  to  the  third  carriage  from  the  rear  of  the  train,  but  failing, 
had  fallen  behind  it,  and  how  the  remaining  coaches  had  then 
passed  over  him.  To  this  account  he  always  adhered,  although 
several  railway  servants,  who  saw  the  occurrence,  noticed  that  he 
jumped  at  and  missed  the  last  carriage,  and  fell  hehind  the  whole' 
train,  nothing  passing  over  him.  As  in  this  case  there  was  no 
question  of  compensation,  we  may  safely  assume  that  the  gentle- 
man believed  his  own  dream. 

Like  the  explosive  manifestations  above  mentioned,  these 
symptoms  are  seldom  of  long  duration, -nor  are  they  necessarily 
followed  by  anything  more  severe.  The  patient  doubtless 
believes  his  visions  to  his  dying  day,  but  they  do  him  no 
harm.  These  conditions,  however,  appear  to  me  to  be  of  the 
greatest  interest  in  connection  with  the  pathology  of  traumatic 
hysteria,  to  which  we  shall  refer  later,  as  indicating  the  iden- 
tity, so  strongly  insisted  upon  by  Charcot,(^'^)  of  the  "  chronic  " 
results  of  traumatic  hysteria  and  of  hypnotic  hysteria — this  stage 
corresponding  as  accurately  as  possible  to  that  of  the  minor 
degrees  of  hypnotism. 

(2.)  Chronic  Hysteria. — Having  thus  cleared  the  ground  by 
noting  the  early  hysterical  symptoms,  we  turn  to  those  which  are 
much  more  persistent  in  their  nature,  and  which  we  may  call 
"  chronic "  or  "  stable "  hysteria.  It  is  not  my  intention  to 
enumerate  all  the  possible  manifestations  of  the  disease — this  has 
frequently  been  done  by  others — and  I  shall  refer  mainly  to  my 
own  cases,  merely  calling  attention,  in  passing,  to  their  chief 
points  of  interest.  Let  it  be  premised  only  that  the  symptoms 
may  be  (i)  psychical,  including  epileptiform  attacks  and  hysterical 
insanity ;  (2)  motor,  including  paralysis  and  contractures  of  the 


TllAUMATIC    HYSTERIA.  1 95 

limbs,  and  special  effects  upon  such  organs  as  tlie  larynx  and  the 
bladder  ;  (3)  sensory  symptoms — anaesthesia,  hyperaDsthesia,  and 
parsesthesise  of  the  general  or  special  sensory  nerves ;  and  (4) 
vaso-motor,  secretory,  and  trophic  troubles.  In  most  cases  there 
are  also  symptoms  which  are  rather  to  be  regarded  as  the  effects 
of  combined  neurasthenia. 


Psychical  Symptoms. — In  considering  the  mental  aberrations  of 
traumatic  hysteria,  we  are  met  by  the  initial  difficulty  that  our 
methods  of  observing  mental  phenomena  are  (except,  perhaps,  in 
the  case  of  trained  alienists)  so  imperfect  that  we  can  hardly 
distinguish  between  true  insanity,  hysteria,  and  mere  neurasthenia. 
The  following  is,  however,  I  believe,  a  case  in  point.  When  I 
first  saw  the  patient,  I  regarded  it  as  a  case  of  hysterical  dementia, 
but  my  friend  Dr.  E.  S.  Reynolds,  after  hearing  my  description, 
classifies  it  as  melancholia  attonita  (melancholia  with  stupor).  It 
seems  further  to  be  an  exaggeration  and  prolongation  of  the  state 
of  acute  hysteria  which  has  already  been  referred  to  as  resembling 
that  of  hypnotism. 


Case  50. — Hysterical  melancholia — Hemiancesthesia. 

A  woman,  aged  twenty-nine,  of  the  lower  classes,  was  hurt  in 
the  collision  at  Hexthorpe  on  September  16,  1887.  When  I 
saw  her  on  October  12,  she  was  confined  to  bed,  and  had  been 
so  since  the  accident.  Owing  to  her  mental  condition,  I  found  it 
almost  impossible  to  obtain  any  definite  information  from  the 
patient,  and  was  obliged  to  depend  mainly  upon  the  statements 
of  her  friends.  She  had  had  severe  bruises  of  the  right  side  of 
the  face,  of  the  left  hand  and  wrist,  and  of  both  ankles.  For 
several  days  she  passed  only  a  small  quantity  of  urine  of  very 
high  colour,  and  she  had  been  troubled  by  constipation,  with 
melaena,  on  several  occasions.  She  suffered  from  a  good  deal  of 
pain  in  the  lumbar  region,  as  well  as  from  that  due  to  the  bruises. 
Both  feet  and  legs  were  almost,  but  not  quite,  absolutely  anaes- 
thetic. The  voice  was  peculiar,  being  very  high-pitched,  appa- 
rently "jerked  out"  with  great  difficulty,  and  very  weak,  besides 
which  there  was  bad  stammering.  The  result  was  that  speech 
was  almost  unintelligible.  Before  the  accident  I  was  told  that 
she   had  a  powerful  voice,  and   made  her  living  as  a  hawker, 


196  SURGERY    OF   THE    SPINAL    CORD. 

and  after  recovery  the  speech  presented  no  abnormality.  She 
had  frequently  had  "  fits  "  since  the  accident,  consisting,  so  far 
as  I  could  learn,  of  convulsive  seizures,  followed  by  coma.  Her 
mental  condition  was  remarkable.  She  had  an  intensely  fright- 
ened "  scared  "  look,  like  that  of  a  wild  animal.  She  paid  little  or 
no  attention  to  her  surroundings,  and  it  was  with  the  greatest 
difficulty  that  she  could  be  got  to  answer  even  simple  questions. 
She  was  quite  incapable  of  connected  speech,  but  there  were  none 
of  the  emotional  manifestations  usually  regarded  as  hysterical. 
Six  weeks  later  I  saw  her  again.  Her  mental  condition  had 
improved;  she  was  able  to  be  up,  and  took  notice  of  her  sur- 
roundings, but  still  had  a  very  "  startled "  appearance  and 
demeanour,  and  did  not  volunteer  any  remarks.  In  answer  to 
questions  she  was  fairly  clear.  Anaesthesia  was  now  localised  on 
the  left  side  of  the  body,  and  was  complete  as  regarded  the  skin. 
The  field  of  vision  in  the  left  eye  (tested  by  the  finger)  was 
diminished  in  size,  that  of  the  right  was  apparently  normal.  The 
stammering  and  laryngeal  symptoms  were  unaltered.  Without 
entering  upon  details,  I  may  say  that  there  were  no  signs  of 
organic  disease,  and  that  her  own  medical  adviser  and  a  dis- 
tinguished consulting  physician  who  saw  her  agreed  with  the 
diagnosis  of  hysteria.  Shortly  afterwards  the  question  of  com- 
pensation was  settled.  By  the  kindness  of  Dr.  Jones  of  Wath- 
upon-Deame,  I  was  enabled  to  see  this  woman  again  on  October 
13,  1888,  more  than  a  year  after  the  accident.  She  suffered  no 
special  inconvenience,  but  said  she  did  not  feel  quite  so  strong  as 
formerly.  The  voice  had  regained  its  normal  character,  and  the 
mind  was  quite  clear.  On  examining  her,  however,  we  found 
sensation  less  perfect  on  the  left  than  on  the  right  side  through- 
out the  body.  The  senses  of  smell  and  taste  were  also  weaker  on 
the  left  side  ;  indeed  that  of  smell  was  almost  entirely  lost.  Hear- 
ing was  unaffected.  The  field  of  vision  of  the  left  eye  was  dis- 
tinctly contracted  in  all  directions,  that  of  the  right  was  diminished 
above  and  below,  but  not  laterally.  (These  tests  were  made  by 
the  finger  only.)  There  was  no  paralysis,  and  both  superficial  and 
deep  reflexes  were  normal.  The  woman  herself  appeared  to  be 
quite  unaware  of  any  deficiency,  and  was  capable  of  attending 
to  her  business.  The  condition  of  this  patient's  optic  discs  was 
one  of  some  interest,  but  the  facts  have  been  sufficiently  related 
above  (p.  182). 

This  case  illustrates  very  clearly  the  condition  of  hysterical 
hemi-anaesthesia,  as  also  a  laryngeal  affection,  to  both  of  which  we 
shall  refer  later.      But  beyond  this  I  am    convinced  that  there 


TRAUMATIC    HYSTERIA.  1 97 

was  for   a   time  a   profound   mental   change,   also   of  hysterical 
origin. 


Case   5  i. — Hysterical  Tnelancholia — Suicidal  impulses — 
ATicesthesia. 

Another  case  was  that  of  a  man,  aged  about  forty,  injured  in 
the  same  accident,  who  besides  bruises  sustained  a  fracture  of  some 
ribs.  He  was  detained  at  Doncaster  for  six  weeks,  and  then 
sent  home,  stated  by  his  attendants  to  be  quite  well.  I  saw 
him  at  his  house  six  months  after  the  accident.  He  complained 
of  pain  about  the  chest,  giddiness,  bad  sleep,  and  other  neuras- 
thenic symptoms,  which  did  not  appear  to  be  very  severe.  He 
also  complained  of  numbness  in  the  right  arm,  and  I  found 
distinct  relative  feebleness  of  sensation  on  the  inner  side  of  the 
right  arm  and  forearm,  but  not  elsewhere.  His  demeanour  was 
that  usually  observed  in  melancholia,  the  peculiar  listless  expres- 
sion and  manner  which  is  better  recognised  than  described,  and 
which  contrasted  markedly  with  the  joviality  of  disposition  which 
he  had  manifested  soon  after  the  accident.  His  wife  said  that 
he  would  often  get  up  in  the  night  and  talk  of  suicide,  and  on 
questioning  him,  he  admitted,  although  not  readily,  occasional 
suicidal  impulses.  He  had,  however,  never  attempted  to  carry 
them  out.  When  I  saw  him,  he  was  already  improving,  and 
as  not  long  afterwards  his  solicitors  settled  his  claim,  we  may 
assume  that,  as  predicted,  recovery  was  satisfactory. 

Interesting  points  in  this  case  are — the  onset  of  mental 
symptoms  after  returning  home,  a  usual  result  in  melancholia ; 
the  abortive  suicidal  ideas  generally  resulting  from  hysterical 
insanity ;  and  the  patient's  own  reticence  on  the  subject.  In 
other  cases  I  have  seen  slight  symptoms  of  melancholia,  and 
sometimes  the  patients  speak  of  suicidal  impulses.  Whether 
these  are,  however,  genuine  cases  of  hysteria,  I  am  not  quite 
sure,  but  in  the  two  above  mentioned,  and  especially  in  the 
first,  the  concurrence  of  well-recognised  hysterical  symptoms 
would  appear  to  be  highly  significant. 

Other  symptoms  of  chronic  traumatic  hysteria,  affecting  the 
higher  cerebral  functions,  are  coma,  convulsions,  and  emotional 
manifestations,  but  these  are  so  well  known  as  to  require  no 
present  remark.  I  may,"'  however,  mention  one  case,  which, 
though  slight,  is  typical,  and  was  very  well  described  by  the 
patient. 


198  SURGERY   OF   THE    SPINAL   CORD. 

Case  52. — Slight  hysteria — Epilepsy. 

A  married  woman,  aged  twenty-eight,  was  injured  in  a  slight 
railway  collision,  receiving  a  cut  over  the  nose,  which  soon 
healed.  She  had  some  not  very  marked  digestive  and  neuras- 
thenic troubles.  But  from  time  to  time  there  came  on  "fits," 
which  she  thus  described : — A  pain  would  suddenly  commence, 
"  sometimes  in  the  feet,  sometimes  in  the  head,  or  other  part  of 
the  body."  She  would  then  go  cold,  and  had  to  sit  down,  feeling 
much  "  confused,"  but  not  actually  losing  consciousness.  In  a 
few  minutes  the  "  fit "  would  pass  off  again.  At  first  the  attacks 
came  on  frequently,  but  a  month  after  the  accident  they  were 
much  fewer,  occurring  only  every  two  or  three  days.  During 
this  time  she  had  been  taking  bromide  of  potassium.  No 
other  symptoms  were  present.  These  seizures  would  seem  to  be 
clearly  of  an  epileptiform  nature,  and  of  hysterical  origin. 

As  these  sheets  are  passing  through  the  press  two  other  cases 
have  come  under  my  notice — one  in  which  a  man,  with  well- 
marked  and  very  obstinate  hemi- anaesthesia  and  a  painful  zone  in 
the  right  groin,  presented  a  most  typical  hystero-epileptic  seizure 
after  manipulation  of  the  latter  region ;  the  other  that  of  a  boy 
who,  after  a  blow  from  a  cricket-ball  in  the  right  groin,  had  several 
epileptic  seizures,  accompanied  by  anaesthesia  of  the  same  side. 

Motor  Symptoms. — Motor  changes  in  the  limbs  occur  in  one  of 
two  forms.  There  may  be  either  flaccid  paralysis  or  spasmodic 
contracture.  This  paralysis  or  contracture  may  affect  the  whole, 
or  less  often  a  segment,  of  one  or  more  limbs.  It  is  always 
limited,  not  by  the  anatomical  distribution  of  nerves,  but  by  the 
physiological  arrangement  of  the  muscles  supplying  the  various 
joints  or  segments.  When  it  takes  a  hemiplegic  or  paraplegic 
form,  we  find  rather  a  double  monoplegia  than  a  genuine  hemi- 
or  paraplegia,  the  muscles  of  the  trunk  and  face  escaping  the 
paralysis.  At  times  the  mouth  is  drawn  to  one  (the  ansesthetic) 
side,  as  if  there  were  facial  paralysis,  but  in  such  cases  there 
is  really  spasm  and  not  paralysis.  Case  53  is  an  instance. 
The  paralysed  muscles  often  undergo  a  good  deal  of  atrophy. 
Their  electric  reactions  remain  normal,  a  point  which  is  of  value 
in  distinguishing  these  cases  from  peripheral  nerve-lesions,  but 
the  resistance  to  the  electric  current  is  increased  in  presence 
of  the  accompanying  anaesthesia  (Vigoureux).  The  muscles  often 
contract   very  readily  on    mechanical   irritation  by  tapping,    or 


TRAUMATIC    HYSTERIA.  1 99 

after  the  application  of  a  bandage  (Charcot).  The  condition  of 
the  tendon  reactions  varies,  but  they  appear  to  be  most  fre- 
quently diminished  in  the  affected  region  (Charcot).  On  the 
other  hand,  in  hemi-ansesthesia  without  paralysis  I  have  usually 
found  the  knee-jerk  increased — a  result  which  may  be  due  to 
the  coincident  neurasthenia.  Anaesthesia  is  apparently  always 
present  in  the  paralysed  regions  (infra),  but  when  there  are  con- 
tractures there  is  usually  great  pain  in  the  region  of  one  of 
the  larger  joints  (arthralgie). 


Case  53. — Hysterical  paralysis  and  hemi-ana;sthesia. 

Dr.  Dreschfeld  has  kindly  allowed  me  to  refer  to  the  following 
case : — G.  S.,  aged  thirty,  a  farm  labourer,  was  admitted  to  Dr. 
Dreschf eld's  wards  on  October  30,  1888.  He  is  a  total  abstainer, 
but  a  heavy  smoker.  No  hereditary  neurotic  taint  can  be  traced. 
His  work  has  always  been  heavy  and  in  the  open  air.  Hitherto 
he  has  been  very  healthy. 

A  year  ago  he  was  covering  a  haystack  with  a  sheet,  when  a 
strong  wind  blew  both  him  and  the  sheet  from  the  top  of  the 
stack  to  the  ground ;  he  did  not  fall  immediately,  but  found  him- 
self going,  and  struggled  vigorously  to  save  himself,  being  at  the 
time  much  frightened.  He  fell  upon  his  head  and  was  unconscious 
for  from  half  to  three-quarters  of  an  hour,  during  which  time  he 
was  conveyed  home  without  his  knowledge.  On  regaining  con- 
sciousness, he  found  a  large  swelling  on  the  left  side  of  the  head, 
but  no  cut,  and  there  was  bleeding  from  the  nose.  During  the 
day  he  felt  weak  but  had  little  pain.  On  the  following  morning 
he  had  headache  and  nausea,  and  vomited  about  half  a  pint  of 
dark  clotted  blood,  but  he  went  to  work.  Since  then,  however, 
he  has  done  scarcely  any  work,  and  has  suffered  from  headache, 
dizziness,  and  almost  daily  vomiting  of  food,  containing  a  little 
blood.  He  has  also  noticed  failure  of  sight  and  hearing,  with 
numbness  and  weakness  of  the  left  side  of  the  body. 

On  admission,  the  man  presented  the  usual  "  facies  hysterica." 
The  upper  and  lower  limbs  on  the  left  side  were  both  very  weak, 
but  they  presented  no  rigidity,  nor  was  there  any  inequality  in 
the  paresis  of  the  various  muscles.  At  first  sight  he  appeared  to 
have  facial  paralysis,  but  careful  observation  showed,  as  is  usual 
in  hysterical  cases,  that  there  was  really  sjMsm  of  the  facial 
muscles  on  the  left  side.  The  mouth  did  not  open  properly,  the 
left  side  being  the  worse.      The  tongue  was  protruded  to  the 


200 


SURGERY    OF   THE   SPINAL    CORD. 


right,  and  that  with  difficulty  only,  owing  to  spasm,  mainly  of  the 
muscles  of  the  left  side  (glosso-labial  hemispasm  of  Charcot). 
There  was  no  dysphagia,  but  mastication  caused  pain  in  the 
maxillary  articulation  of  the  left  side.  The  muscles  presented 
no  fibrillar  tremblings.      They  reacted  to  the  faradic  current. 

Sensibility,  both  superficial  and  deep,  was  completely  lost  over 
the  left  side  of  the  body,  except  at  the  following  points,  viz. : 
(i)  The  region  of  the  bruise,  immediately  behind  the  left  parietal 
eminence;  (2)  the  costal  margin;  and  (3)  the  groin.  In  these 
regions  there  was  hypereesthesia,  and  deep  pressure  on  the  left 

Left. 


006 


^Gh' 


Fio.  33. — Case  53. — The  outer  line  indicates  the  normal,  the  inner  line  the 
actual  boundary  of  the  field  of  vision. 

groin  caused  a  distinct  hysterical  crisis,  with  flushing  of  the  face, 
fixity  of  gaze,  and  rigidity  of  the  body.  Pains  were  complained 
of  '*  all  over  the  body,"  especially  in  the  left  arm  and  leg,  and  in 
the  head,  where  the  frontal  and  sub-occipital  regions  were  most 
painful.  The  spine  was  tender  throughout,  especially  in  the  cer- 
vical and  lumbar  regions.     The  fauces  were  anaesthetic. 

The  special  senses  were  also  affected.  Thus  he  complained  of 
a  constant  bad  taste  in  his  mouth,  and  a  week  after  admission, 
I  found  the  left  side  of  the  tongue  hyperaesthetic  (a  condition 
which  was  also  noticed  in  Case  57).  Hearing  was  impaired  on 
the    left    side,  a  watch    being    audible    at    a   distance    of    five 


TRAUMATIC    HYSTERIA. 


20I 


Indies  from  the  right  ear,  and  half-an-inch  from  the  left.  The 
pupils  were  normal.  Movements  of  the  eyeballs  caused  pain. 
Eyesight  was  impaired,  and  the  field  of  vision  was  found  to  be 
peripherally  contracted  in  both  eyes,  but  especially  in  the  left, 
in  which  it  was  reduced  almost  to  fixation  point.  The  accom- 
panying perimetric  tracings  were  taken  a  week  after  admission, 
when  the  man  was  rapidly  recovering,  and  are  no  guide  to  the 
extent  of  the  contraction  of  the  field  when  first  seen,  but  indicate 
the  differences  between  the  eyes.  A  most  remarkable  point  is, 
that  the  field  of  vision  of  the  right  eye  is  abnormally  large,  a 


Bight. 


ao 


105 


-JOft 


IflS' 


Fig.  34. — Case  53. — The  inner  line  represents  the  normal,  the  outer  the  actual 
boundary  of  the  field  of  vision. 

condition  which  I  have  since  seen  very  well  developed  in  another 
and  most  typical  case.  In  this  connection  it  is  interesting  to 
note  that  in  hysterical  paralysis  the  healthy  side  has  been  found 
to  present  an  increase  of  power  (F^r^),  and  possibly  we  may  here 
have  an  increased  sensory  activity,  enabling  the  extreme  anterior 
portion  of  the  retina,  which  is  usually  without  function,  to  ac- 
quire some  perceptive  power. 

The  reflexes  were  normal  throughout,  except  that  the  right 
knee-jerk  was  somewhat  exaggerated  and  the  left  plantar  reflex 
was  lost. 

There  was  frequent  vomiting,  sometimes  of  blood. 


202  SURGERY    OF   THE    SPINAL    CORD. 

The  treatment  was  solely  expectant,  with  confinement  to  bed, 
and  after  an  interval  of  less  than  three  weeks  from  the  date  of 
his  admission,  the  patient  was  so  far  recovered  that  he  had  but 
little  remnant  of  either  paralysis  or  anaesthesia. 

In  the  above  case  the  tongue  was  deflected  to  the  right,  i.e., 
away  from  the  paralysed  side,  owing,  apparently,  to  spasm  of 
the  genio-hyoglossus  muscle  of  the  left  side ;  but  in  two  cases 
which  I  have  since  seen,  the  tongue  has  been  deflected  toivards 
the  anaesthetic  side.  In  one  of  these  there  was  on  the  anaesthetic 
side  very  well-marked  hardening  from  spasm  of  the  intrinsic 
muscles  of  the  tongue,  so  that  the  deflection  here  arose,  not  from 
an  irregular  projection  of  the  organ,  but  from  an  internal  derange- 
ment of  its  shape.  In  neither  of  the  two  latter  cases  were  the 
facial  muscles  affected. 


Case  54. — Hysterical  contraction  of  upper  limb — Paralysis — 
Anaesthesia  and  arthralgia. 

For  permission  to  use  the  following  case  I  am  indebted  to  Dr. 
Leech,  under  whose  care  the  patient  was  admitted  to  the  Man- 
chester Infirmary.  A  girl,  aged  eighteen,  fell  about  Christmas 
1885  on  to  her  left  shoulder.  She  attended  at  the  accident- 
room  of  the  Infirmary,  and  appears  to  have  had  her  left  arm 
bandaged  across  the  chest  for  some  weeks.  From  the  accounts 
given,  this  would  seem  to  have  been  followed  by  cellulitis  about 
the  shoulder  and  arm.  Hereafter,  the  limb  became  useless  and 
caused  her  intense  pain,  so  great  that  she  was  anxious  to  have  it 
amputated. 

On  June  13,  1888,  she  was  admitted  to  Dr.  Leech's  wards. 
The  left  upper  limb  was  held  rigidly  to  the  side,  with  the  elbow 
and  wrist  flexed,  and  the  fingers  bent  in  upon  the  palm.  It 
was  much  wasted,  and  the  muscles  were  rigid.  The  various 
joints  could  be  moved  only  by  the  use  of  considerable  force,  and 
active  resistance  to  such  movements  could  be  felt.  The  girl 
complained  of  intense  pain  on  movement,  especially  of  the 
shoulder,  and  of  great  tenderness  about  the  latter  joint.  So 
great  was  her  pain,  that  sleep  was  almost  entirely  lost,  and  she 
was  being  rapidly  worn  out.  She  had  absolute  superficial  and 
deep  anaesthesia  of  the  forearm  and  lower  part  of  the  arm,  but 
great  hyperaesthesia  of  the  upper  part  of  the  latter,  and  there 
was  some  diminution  of  sensation  of  the  whole  of  the  left  side  of 


TRAUMATIC    HYSTERIA.  203 

the  body,  •with  distinct  contraction  of  the  field  of  vision  on  that 
side.  The  muscles  of  the  left  upper  limb  reacted  normally  to 
the  faradic  current. 

Besides  these  symptoms,  she  had  "  hsematemesis,"  which  was 
found  to  be  due  to  sucking  a  small  abrasion  inside  the  mouth. 
Her  general  appearance  was  markedly  hysterical. 

Careful  observation  showed  that,  when  unaware  that  any  of 
the  medical  staff  or  nurses  were  watching  her,  she  made  very  fair 
use  of  her  left  arm,  having  much  greater  power  in  it  than  she 
professed  to  have. 

Under  these  circumstances  she  was  treated  by  massage,  fara- 
dism  of  the  limb,  internal  administration  of  tine,  valerian,  ammon., 
and  careful  moral  supervision  and  instruction ;  the  result  being 
that  when  she  left  the  hospital  a  month  after  admission,  she  had 
lost  the  pain,  and  acquired  a  very  considerable  amount  of  power  in 
the  limb,  the  nutrition  of  which  was  rapidly  improving.  This  is 
a  case  of  contracture,  involving  mainly  the  most  usual  seat — the 
shoulder-joint.  Many  similar  cases  are  recorded  by  Charcot  and 
others. 

Besides  these  paralyses  of  limbs,  it  is  not  uncommon  to  find 
motor  troubles  in  connection  with  the  larynx  and  the  bladder. 
In  two  cases  I  have  seen  affections  of  the  larynx,  one  being 
Case  50,  already  quoted  as  an  illustration  of  mental  defect;  the 
other  is  as  follows  : — 


Case  5  5 . — Hysterical  ^paralysis  of  adductors  of  glottis. 

A  girl,  aged  nineteen,  was  injured  in  a  slight  railway  collision. 
I  saw  her  on  the  following  day,  and  learned  that  in  the  morning 
she  had  gone  to  her  work,  but,  feeling  too  ill  to  continue  it,  had 
returned  home  and  gone  to  bed.  She  had  since  slept  a  good 
deal.  She  said  that  she  had  been  senseless  for  a  short  time  after 
the  accident,  and  since  then  she  had  had  a  good  deal  of  pain  from 
bruises  of  both  knees  and  arms  and  of  the  side  of  the  neck.  One 
symptom,  which  I  was  told  by  her  medical  attendant  had  come 
on  since  the  morning,  was  a  marked  hoarseness  and  aphonia, 
sometimes  passing  into  a  mere  whisper,  just  as  in  a  laryngitis. 
She  had  no  cold,  but  under  the  circumstances  it  did  not  seem 
advisable,  nor  was  it  practicable,  to  make  any  examination  of 
the  throat  or  larynx.  Here,  as  in  Case  50,  there  appears  to 
have  been  a  temporary  paralysis  of  the  adductors  of  the  vocal 
cords.  Six  weeks  later  I  saw  the  girl  again,  and  learnt  that  the 
vocal  trouble  had  passed  away  in  a  few  days.     She  then  presented 


204  SURGERY    OF   THE   SPINAL    CORD. 

only  vague   neurasthenic  symptoms,  with  well-marked   neurotic 
dyspnoea,  which  were  gradually  subsiding. 

Retention  of  urine,  again,  is  a  very  frequent  result.  I  refer 
to  it  in  several  of  my  cases,  but  will  here  give  one  where  it  was 
the  chief  symptom,  and  in  which  the  amount  of  the  secretion 
appeared  to  be  considerably  diminished. 


Case  56. — Hysterical  retention  of  urine. 

A  charwoman,  aged  thirty-eight,  was  in  a  railway  collision 
under  the  peculiar  circumstances  already  mentioned,  as  illustrative 
of  the  effect  of  fear,  apart  from  physical  injury.  She  certainly 
sustained  no  bruises,  but  was  frightened,  and  may  have  been 
slightly  shaken.  Almost  immediately  after  the  accident  severe 
"  flooding"  came  on.  I  saw  her  two  days  afterwards,  when  she 
complained  of  great  pain  in  her  head  and  abdomen :  the  flood- 
ing still  continued,  but  was  diminishing :  the  bowels  had  not 
been  moved  since  the  accident,  and  she  had  only  passed 
urine  once :  the  pulse  was  feeble,  y6.  There  was  no  sign  of 
organic  injury.  A  week  later  I  saw  her  again.  She  was 
feeling  much  better,  and  the  flooding  had  ceased,  but  she  still 
felt  very  weak  and  "  all  of  a  tremble,"  and  she  had  only  passed 
urine  five  times  in  nine  days.  Prom  this  time  she  made  a  rapid 
recovery,  and  a  few  weeks  later  I  learned  that  she  was  well. 
Owing  to  legal  reasons,  no  compensation  could  be  claimed,  a  point 
which  was  decided  within  a  few  days  of  the  accident,  and  which 
generally  expedites  recovery. 

Temporary  retention  of  urine  is  a  very  common  result  of 
shock,  seen  constantly  after  railway  and  other  accidents ;  but 
such  retention  usually  passes  off  within  at  most  forty-eight  hours. 
Here  the  condition  was  so  prolonged  as  to  merit  in  my  opinion 
the  designation  of  hysterical.  In  the  above  case  the  catheter  was 
not  used,  and  this  is  undoubtedly  the  true  principle  of  treatment. 
If  once  operative  relief  be  given,  the  condition  may  be  indefinitely 
prolonged ;  whereas,  if  the  patient  be  left  alone,  micturition  will 
almost  always,  if  not  always,  be  shortly  accomplished.  It  is  of 
course  necessary  before  deciding  to  leave  the  case  untouched  to 
make  sure  that  there  is  no  organic  injury,  either  to  the  urinary 
or  the  nervous  system  ;  but  having  made  the  diagnosis,  we  should 
follow  the   invariable   rule  of    ignoring  as   far   as    possible  the 


TRAUMATIC    HYSTERIA.  205 

hysterical  symptoms.  I  shall  refer  later  to  another  case  of 
retention  of  urine  with  other  hysterical  symptoms,  which  termi- 
nated in  death  (Case  66). 

Sensory  symptoms. — Before  summarising  the  various  sensory 
phenomena  met  with  in  traumatic  hysteria,  it  will  be  convenient 
to  refer  to  certain  illustrative  cases. 


Case  57. — Hysterical  hemi-ancesthesia — Paresis  and  torticollis. 

On  August  I,  1888,  there  presented  herself,  among  Mr. 
Wright's  out-patients  at  the  Manchester  Infirmary,  a  woman, 
aged  thirty-eight,  seven  years  a  widow,  and  with  one  child.  She 
gave  the  following  account  of  herself.  About  nine  weeks  pre- 
viously, she  had  fallen  down  a  narrow  staircase  of  some  thir- 
teen steps,  striking  her  head  at  the  bottom  in  such  a  way  as  to 
bend  the  neck  forwards  and  force  the  head  between  the  knees. 
Her  sister  ran  to  her,  and  says  she  found  her  black  in  the  face ; 
she  seized  the  head  and  threw  it  back.  The  patient  was  then 
put  to  bed,  and  could  not  walk  for  five  weeks.  A  medical  man, 
who  saw  her,  told  her  that  the  head  had  been  *'  put  out"  and 
**  put  in  again."  While  confined  to  bed  she  had  a  succession  of 
"  fits,"  and  her  head  became  drawn  to  one  side ;  for  some  days 
she  seems  to  have  been  comatose,  and  to  have  had  unconscious 
evacuations ;  for  more  than  a  week  she  could  not  move  her  right 
arm,  but  the  left  was  "  all  right." 

When  I  saw  her,  she  complained  of  pain  on  the  left  side, 
chiefly  in  the  region  of  the  mastoid  process,  but  affecting  the 
whole  of  that  side  of  the  head  and  neck,  as  well  as  of  pain 
behind  the  right  shoulder.  The  head  was  firmly  drawn  over  to 
the  right  side,  and  both  sterno-mastoid  muscles  were  very  tense. 
She  complained  also  of  difiiculty  in  swallowing,  with  well-marked 
globus,  and  of  imperfect  vision. 

The  demeanour  was  distinctly  hysterical.  She  had  no  para- 
lysis, but  would  not  move  her  right  arm  freely,  owing  to  the 
pain  caused  thereby,  nor  was  there  any  muscular  atrophy.  The 
knee-jerks  were  a  little  exaggerated.  The  right  arm  was  par- 
tially anaesthetic,  and  the  visual  fields,  tested  by  the  finger,  were 
both  much  diminished  in  extent. 

The  patient  was  sent  into  the  Infirmary,  and  I  re-examined  her 
two  days  later.  The  aneesthesia  of  the  right  upper  limb  was  now 
much  more  marked,  and  was  bounded  by  a  line  running  right 


206 


SURGERY    OF    THE    SPINAL   CORD. 


round  the  limb  at  its  junction  with  the  trunk,  i.e.,  over  the  tip  of 
the  acromion  and  across  the  axilla.  She  was  unable  to  localise 
the  position  of  the  limb  when  her  eyes  were  closed.  The  sensa- 
tion of  the  legs  was  not  affected.  She  had  hyperaesthesia  of 
the  right  mamma  and  of  the  cervical  and  mid-dorsal  regions  of 
the  spine.  The  right  ovarian  region  was  also  markedly  hyper- 
aesthetic,  pressure  over  it  causing  flushing  of  the  face,  screaming, 
and  clonic  facial  spasm,  followed  by  exhaustion,  which  lasted  for 
some  minutes. 

The  patient   was   now   removed   to   the   medical   wards,    and 
placed  under  the  care  of    Dr.  Dreschfeld,  where  I  believe  she 

Lefi. 


90 


106 


IBO 


Fio.  3S.— Case  57.— The  outer  line  indicates  the  normal,  the  inner  line  the 
actual  boundary  of  the  field  of  vision. 

improved  considerably,  and  whence  she  was  shortly  afterwards 
discharged. 

On  September  8  th  she  came  to  me  again,  saying  she  was  as 
bad  as  ever,  and  was  getting  weaker.  She  had  now  the  same 
deflection  of  her  neck  as  before.  Anesthesia  affected  the  whole 
of  the  right  side  of  the  body,  including  the  tongue  and  fauces  on 
the  same  side.  She  was  unable  to  swallow  solids.  Otherwise 
her  condition  was  as  when  first  seen.  The  perimetric  tracings 
(figs.  35  and  36)  show  a  field  of  vision  considerably  and  almost 
equally  contracted  in  both  eyes.  The  knee-jerks  were  normal  on 
both  sides. 


TRAUMATIC    HYSTERIA. 


207 


She  was  again  made  an  in-patient  under  Dr.  Dreschfeld,  and 
three  weeks  later  she  professed  herself  much  better.  There  was 
no  pain,  except  a  little  in  the  neck,  when  she  had  been  sitting 
up  for  some  time,  and  she  had  slight  tenderness  of  the  cervical 
and  mid-dorsal  regions  of  the  spine.  Sensation  was  very  slightly 
duller  on  the  right  than  on  the  left  side,  no  difference  being 
observed  in  the  palate  and  throat,  but  the  right  side  of  the 
tongue  was  hypermsthetic,  as  in  Case  53.  The  head  was  almost 
straight,  vision  was  good,  and  the  globus  had  vanished.      The 


BlOHT. 


ISO 


Fig.  36.— Case  57. — The  outer  line  indicates  the  normal,  the  inner  line  the 
actual  boundary  of  the  field  of  vision. 

treatment  consisted  in  daily  faradisation  of  the  back  of  the  neck, 
with  internal  administration  of  bromide  of  potassium. 


This  case  illustrates  very  clearly  the  condition  of  unilateral 
anaesthesia  with  associated  hypergesthetic  regions  and  hysterogenic 
points.  The  contraction  of  the  visual  field  of  both  eyes,  which 
was  here  seen,  is  not  very  usual,  the  common  condition  being  for 
this  change  to  occur  either  solely,  or  far  more  markedly,  on  the 
anassthetic  side. 


208  SURGERY   OF    THE    SPINAL   CORD. 

Case  58. — Hysterical  hemi-anmsthesia. 

A  man,  aged  thirty-five,  was  injured  in  the  railway  accident 
at  Hexthorpe  on  September  16,  1887,  being  in  a  carriage 
which  was  smashed  to  pieces.  He  told  me  that  at  the  time  of 
the  accident  he  lost  his  eyesight,  and  then  became  unconscious, 
from  which  description  I  assume  that  he  fainted.  In  this  con- 
dition he  was  removed  to  the  Doncaster  Infirmary,  and,  recover- 
ing consciousness  on  the  road  thither,  he  says  that  he  found 
his  right  "  knee-caj) "  displaced  outwards,  and  that  he  replaced 
it  with  his  hands.  When  I  saw  him,  he  was  suffering  from  the 
usual  symptoms  of  shock,  together  with  bruises  of  both  legs,  most 
severe  on  the  right  side,  especially  in  the  region  of  the  knee- 
joint,  and  from  a  bruise  of  the  front  of  the  chest,  and  a  cut  on 
the  left  side  of  the  occiput  about  three  inches  long.  He  was 
very  nervous,  and  on  the  following  day  we  had  great  difiiculty 
in  persuading  him  that  there  was  no  fracture  of  the  ribs  or 
"breast-bone."  For  some  weeks  he  was  retained  in  Doncaster, 
and  was  then  sent  home,  supposed  to  be  convalescent. 

I  saw  this  man  again,  at  his  own  house,  on  November  7, 
1887,  and  on  two  subsequent  occasions,  the  last  being  on  March 
10,  1888,  when  I  was  accompanied  by  Dr.  Ross.  On  the 
first-named  date  he  was  in  bed,  and  said  he  had  been  so  ever 
since  the  accident.  He  complained  of  great  pain  across  the 
back  of  the  head,  difiiculty  of  breathing,  anxiety — especially  at 
night — and  constant  coldness  of  the  feet.  He  said  that  he 
could  not  see  properly  with  the  right  eye,  and  that  the  right 
leg  had  never  been  straight  since  the  accident.  The  latter 
statement  was  certainly  incorrect,  as  there  was  no  change  in 
the  shape  of  the  limb,  except  that  due  to  old  genu  valgum, 
which  was  slight,  and  equally  marked  on  both  sides.  I  found 
no  anaesthesia  in  the  lower  limbs,  but  did  not  then  test  the  upper 
extremities  or  the  fields  of  vision. 

Later,  when  he  began  to  walk,  he  found  that  the  right  leg 
would  often  "  give  way  under  him,"  and  he  thought  he  had  to 
raise  it  higher  than  he  used  to  do.  He  also  had  to  watch  the 
ground  to  see  where  he  put  it,  and  had  twice  fallen.  He  now 
had  distinct  right-sided  hemi-angesthesia,  not  absolute,  but  very 
well  marked,  and  shaqoly  bounded  by  the  middle  line  of  the 
body.  This  anaesthesia  affected  the  senses  of  taste  and  smell. 
On  the  left  side  he  could  hear  a  watch  at  the  distance  of  five 
inches,  on  the  right  side  at  a  distance  of  one  inch  only.  The 
visual  field,  tested  by  the  finger,  was  slightly  retracted  on  the 


TRAUMATIC    HYSTERIA.  209 

left  side,  but  very  markedly  so  on  the  right.  Objects  looked 
at  with  the  right  eye  he  described  as  if  seen  through  gauze. 

Shortly  after  my  last  visit,  in  March,  his  claim  was  settled  by 
the  railway  company,  and  in  May  I  heard  that  he  was  much 
better,  but  that  the  right  leg  still  occasionally  gave  way,  and 
that  the  sight  of  the  right  eye  remained  a  little  dim — symptoms 
which  were  passing  off. 

This  is  another  typical  case  of  right  hemi-anaesthesia  affecting 
all  the  sense  organs.  The  difficulty  in  walking  and  the  descrip- 
tion given  by  the  patient  of  the  attention  which  he  had  to 
bestow  upon  the  right  leg  in  doing  so  are  characteristic  of  the 
loss  of  muscular  sense  or  localising  power  in  that  limb,  and 
there  was  not  a  trace  of  real  paralysis,  and  no  atrophy. 


Case   59. — Hysterical  hemi-ancesthesia. 

Another  similar  case  is  that  of  a  man,  aged  forty-two,  who 
was  hurt  in  a  slight  railway  collision  on  August  29,  1888.  On 
the  following  day  I  found  him  in  bed  in  a  semi-stupid  con- 
dition. He  was  unable  to  give  any  clear  account  of  his  acci- 
dent, but  I  learnt  that  he  had  had  three  fits  in  the  short  jour- 
ney which  he  had  to  take  to  reach  home,  and  that  on  getting 
there  he  was  insensible.  He  complained  of  pain  in  the  head, 
back,  and  abdomen,  and  there  were  bruises  of  the  back  and  head. 
The  pulse  was  slow  (56)  and  full.  Beyond  this  he  presented 
no  sign  of  injury. 

A  fortnight  later,  when  I  saw  him  again,  he  was  feeling  much 
better,  and  was  up  out  of  bed.  He  now  complained  of  pain  in 
the  head,  chest,  and  left  arm,  and  of  feeling  dazed  when  walk- 
ing. He  said  also  that  sometimes  he  could  not  move  his  left 
arm  at  night,  but  could  do  so  in  the  daytime.  Sensation  was 
very  deficient  on  the  whole  of  the  left  side.  In  the  right  eye, 
the  field  of  vision,  as  tested  by  the  finger,  was  equal  to  my 
own ;  but  in  the  left  it  was  reduced  almost  to  the  fixation 
point.  He  had  also  achromatopsia  on  the  left  side,  but  none 
on  the  right.  There  was  no  paralysis,  and  the  superficial  and 
deep  reflexes  were  normal.  He  complained  somewhat  of  rest- 
less sleep  and  a  poor  appetite. 

Six  months  later,  on  January  29,  1889,  he  was  suffering 
from  pain  in  the  back  of  the  head,  and  from  some  pain  and 
weakness  in  the  lower  part  of  the  back,  but  the  anjesthesia  and 
visual  affection  had  disappeared.      About  a  fortnight  after  this 

0 


2IO  SURGERY   OF   THE   SPINAL    COED. 

date,  and  immediately  before  a  legal  inquiry  into  the  amount  of 
compensation  to  be  awarded,  the  man  was  again  examined  by 
Dr.  Eoss,  who  found  slight  left-sided  hemi-anaesthesia.  The 
progress  of  the  case  after  the  settlement  of  compensation  is 
unknown  to  me. 

Here  we  have  a  note  of  a  condition  which  is  usually  found, 
namely,  achromatopsia,  on  the  same  side  as  the  diminished  field 
of  vision,  the  two  symptoms  generally,  though  not  always, 
occurring  together.  The  supposed  inability  to  move  the  left 
arm  in  the  dark  was,  doubtless,  due  to  the  impossibility  of 
localising  its  position,  there  being  no  muscular  weakness.  An 
interesting  and  not  very  unusual  condition  is  the  disappearance 
and  subsequent  return  of  hysterical  symptoms.      (See  p.  223.) 

The  next  two  cases  are  examples  of  less  extensive  ansesthesia. 


Case  60. — Hysterical  ancesthesia. 

A  man,  thirty-one  years  of  age,  was  injured  in  a  railway 
collision,  thirteen  days  after  which  I  saw  him  for  the  company 
concerned.  He  stated  that  for  a  short  time  he  was  stunned, 
that  he  afterwards  vomited,  and  that  he  had  been  confined  to 
bed  for  about  ten  days.  He  had  a  bruise  on  the  left  elbow,  and 
another  over  the  base  of  the  second  right  metacarpal  bone.  In 
addition  to  these  troubles,  he  complained  of  pain  in  the  epi- 
gastrium and  lower  lumbar  spine  and  in  the  back  of  his  head. 
For  the  first  few  days  he  was  said  to  have  passed  blood  both 
with  his  faeces  and  his  urine,  but  this  had  ceased  when  I  saw  him. 
There  were  then  no  signs  of  organic  injury.  He  had,  however, 
the  following  clearly  hysterical  symptoms : — He  complained  of  a 
noise  in  the  left  maxillary  articulation  on  movement  of  the 
jaw,  which  was  due  to  his  partially  slipping  the  condyle  off 
its  articulating  surface.  He  had  "numbness,"  not  always  con- 
stant, together  with  a  sense  of  pricking  in  the  right  upper  limb. 
Here  I  found  a  patch  of  ansesthesia  on  the  palm  of  the  hand, 
and  another  small  patch  in  front  of  the  fore-arm,  a  short 
distance  below  the  elbow-joint.  He  said  he  could  not  see  as 
well  as  formerly,  the  letters  running  together  when  he  tried 
to  read.  I  did  not  at  that  time  examine  his  visual  fields,  but  this 
was  done  a  few  days  afterwards  by  Dr.  Hill  Griffith,  who  has 
kindly  given  me  the  annexed  perimetric  tracings,  and  who  tells 
me  that  he  found  no  achromatopsia.  A  fortnight  later  I  heard 
from  his  medical  attendant  that  he  was  much  better,  and  that 


TRAUMATIC   HYSTEEIA. 


211 


another  consultation  was  not  required,  and  a  few  days  thereafter 
he  accepted  compensation  for  his  injuries  and  resumed  his  work. 


Case  6i. — Hysterical  ancesthesia. 

A  man,  aged  twenty-seven,  was  injured  in  the  same  collision 
as  the  patient  last  mentioned,  and  I  saw  him  for  the  company 
concerned  three  weeks  later.  He  said  he  had  vomited  blood 
almost  immediately  after  the  collision,  but  had  only  done  so  once. 

Left. 


180 


Fig.  37. — Case  60. — The  outer  line  indicates  the  normal,  the  inner  line  the 
actual  boundary  of  the  field  of  vision. 

He  had  since  had  pain  in  the  head,  back,  and  abdomen,  with 
shooting  pains  in  the  left  lower  limb  running  from  the  hij)  to  the 
foot.  There  was  tenderness  about  the  umbiliciis  and  the  second 
lumbar  vertebra,  and  on  either  side  of  the  latter,  but  no  deformity. 
The  tongue  was  furred ;  the  pupils  rather  insensitive.  In  the  left 
groin  there  was  some  hyperassthesia,  and  the  left  thigh  and  leg 
were  less  sensitive  than  the  right.  The  cremasteric  reflex  was 
normal  and  equal  on  both  sides,  the  knee-jerks  lively,  especially 
on  the  left  side.  There  was  no  trace  of  paralysis.  Both  visual 
fields  (tested  by  the  finger)  were  markedly  and  equally  contracted. 
Three  weeks  later  the  anaesthesia  was  not  sufficiently  marked  to 


212 


SURGERY    OF    THE    SPINAL   CORD. 


be  registrable  by  the  aesthesiometer ;  the  hyperaesthesia  had  dis- 
appeared, as  had  the  eye  symptoms,  and  the  chief  complaint  was 
of  pain  in  the  back.  The  left  knee-jerk  was  still  the  more  lively. 
Here  the  combined  anaesthetic  and  hyperaesthetic  areas  might 
have  led  to  a  suspicion  of  organic  affection,  probably  a  sprain  of 
the  spinal  column  with  some  pressure  on  the  nerve-roots,  but  the 
clue  to  the  diagnosis  is  given  by  the  visual  changes,  as  well  as  by 
the  absence  of  all  motor  symptoms. 

Nearly  a  year  after  the  accident  I  saw  this  patient  again  with 
Mr.  Jessop  of  Leeds.      He  was  then  suffering  from  various  neur- 


RlGHT. 


-105 


ISO 


Fig.  38.— Case  60.— The  outer  line  indicates  the  normal,  the  inner  line  the 
actual  boundary  of  the  field  of  vision. 

asthenic  symptoms — pain  and  intense  hyperaesthesia  of  the  back, 
dyspepsia,  &c. — but  he  had  no  anaesthesia  or  affection  of  the  fields 
of  vision.  Shortly  afterwards  he  received  compensation,  and  a 
month  after  the  settlement  of  his  claim  his  solicitor  informed  me 
that  he  was  quite  well  and  had  returned  to  his  occupation  as  a 
bookmaker's  assistant. 

The  following  case  illustrates  in  a  remarkable  manner  the 
difficulties  which  may  arise  in  diagnosis,  owing  to  the  fact,  to 
which  reference  has  already  been  made,  that  an  organic  lesion 
of  one  or  more  peripheral  nerves  may  give  rise  to  hysterical 
symptoms. 


TRAUMATIC   HYSTERIA.  213 

Case  62. — Injur]/  to  left  crural  plexus — Svhseguent  hysterical 
Jiemi-ancesthesia. 

A  woman,  thirty-two  years  of  age,  who  was  in  the  Hexthorpe 
railway  collision,  was  jerked  violently  forwards,  and  then  fell 
back,  with  her  left  side  on  the  arm  of  the  carriage-seat.  She 
gave  the  following  account  of  herself: — After  the  accident  she 
was  able  to  walk  some  little  distance,  but  in  an  hour  or  so  there 
came  on  intense  pain  of  the  left  thigh  and  leg,  shooting  down 
the  back  of  the  limb.  In  the  course  of  the  evening  this  pain 
disappeared  completely,  and  was  followed  by  loss  of  sensation  and 
paralysis  of  the  limb.  The  latter  symptoms  continued  for  some 
three  weeks,  and  at  the  end  of  that  period  anaesthesia  was 
beginning  to  pass  off  and  to  be  again  replaced  by  pain.  When 
I  saw  the  woman,  she  had  pain  in  the  lumbar  spine,  with  loss  of 
sensation  of  the  left  lower  limb  and  diminution  of  the  knee-jerk 
on  that  side.  I  made  a  more  complete  examination  six  weeks 
later.  The  patient  then  complained  of  tenderness  over  the  first 
and  second  lumbar  vertebrae.  She  had  anaesthesia  of  the  whole 
of  the  left  lower  limb,  except  over  a  strip  of  skin  extending 
from  the  inguinal  canal  towards  the  inner  side  of  the  knee,  and 
thence  down  the  inner  side  of  the  leg  to  about  the  middle  of 
the  tibia.  This  band  was  broader  above  than  below,  and  here 
sensation,  although  not  absolutely  lost,  was  feeble.  Aneesthesia 
extended  over  the  gluteal  region,  and  was  limited  by  a  line 
corresponding  accurately  to  the  lower  margin  of  the  distribution 
of  the  ilio-inguinal  and  ilio -hypogastric  nerves,  which  had  escaped. 
There  was  no  paralysis.  The  plantar  reflex  was  absent,  the 
patellar  less  marked  than  on  the  right  side,  but  still  quite  dis- 
tinct.     She  had  had  no  urinary  or  bowel  trouble. 

Here  I  diagnosed  a  sprain  of  the  lumbar  spine,  or  a  bruise 
from  falling  back  on  to  the  seat  of  the  carriage,  with  injury  to 
the  nerves  of  the  lumbar  and  sacral  plexuses  on  the  left  side, 
there  being  anaesthesia  in  the  distribution  of  all  the  roots  below 
the  third  lumbar  (cf.  chap,  v.) ;  resting  the  opinion  upon  the 
grounds  that  the  anaesthesia  followed  the  anatomical  distribu- 
tion of  the  nerves  rather  than  the  segmental  arrangement  which 
obtains  in  hysteria ;  that  the  condition  of  the  reflexes  was  in 
accordance  with  it ;  and  that  the  history  of  the  mechanism  of  the 
injury  was  also  in  agreement.  The  disappearance  of  paralysis 
before  that  of  the  anaesthesia  does  not  militate  against  this  view, 
as,  r,after  injuries  to  nerve-trunks,  the  sensory  may  persist  long 
after  the  motor  symptoms. 


2  14  SURGERY   OF   THE   SPINAL   CORD. 

A  year  later  I  saw  this  woman  again,  with  her  medical  adviser, 
Dr.  Jones,  of  Wath.  I  then  learned  that  after  my  last  visit  she 
had  developed  anaesthesia  of  the  whole  of  the  left  side  of  the 
body,  and  that  the  angesthesia  was  not  of  uniform  intensity,  but 
came  and  went  from  time  to  time.  The  compensation  was  settled, 
and  rapid  recovery  ensued.  When  I  saw  the  woman,  after  so 
long  an  interval,  there  were,  however,  certain  persistent  symp- 
toms. She  said  she  had  occasional  pricking  sensations  of  the 
left  buttock  and  of  the  back  of  the  left  thigh ;  she  frequently  felt 
as  if  there  were  something  in  her  left  boot,  and  she  could  not 
stand  on  the  left  leg  alone,  as  she  could  do  on  the  right.  I  found 
some  diminution  of  sensation  of  the  whole  of  the  left  side  of  the 
body,  including  the  senses  of  hearing,  taste,  and  smell.  The  left 
field  of  vision  was  distinctly  contracted,  the  right  normal.  In  the 
case  of  the  left  lower  limb,  sensation  was  much  less  acute  on  the 
buttock  and  back  of  the  thigh  than  on  the  front  of  the  latter, 
and  less  also  on  the  outer  than  on  the  inner  side  of  the  leg,  i.e., 
there  was  greater  disturbance  of  the  sciatic  and  its  branches  than 
of  the  anterior  crural.  The  plantar  reflex  was  absent  on  the  left 
side,  normal  on  the  right ;  the  knee-jerks  were  equal.  The 
patient  said  most  distinctly  that  none  of  her  symptoms  interfered 
with  her  comfort  or  usefulness. 

Here,  then,  I  believe  that  to  the  original  organic  injury  we 
had  superadded,  at  a  much  later  date,  a  typical  hysterical  hemi- 
anaBsthesia,  both  of  which  could  be  traced  at  the  last  examination. 

It  is  unnecessary  to  multiply  instances  of  traumatic  hysterical 
anaesthesia.  But  I  may  add  that  in  some  cases  which  I  believe 
to  have  been  hond  fide,  I  have  found  affection  of  the  special  senses 
only.  Thus  I  have  notes  of  four  cases  of  marked  deafness,  one 
of  which  was  combined  with  feebleness  of  the  grasp  and  "  numb- 
ness "  in  the  hands,  but  not  with  actual  loss  of  tactile  sensibility. 
In  two  cases  the  field  of  vision  was  contracted  in  both  eyes,  but 
there  was  no  other  symptom.  In  these  cases  there  has,  however, 
usually  been  some  previous  weakness  of  the  affected  organ.  Thus 
of  the  four  cases  of  deafness,  three  admitted  having  previously 
been  slightly  deaf,  but  stated  that  they  were  rendered  much  worse 
by  the  accident,  while  one  gentleman  who  had  contracted  field  of 
vision  had  always  been  short-sighted.  It  is  difiicult  under  such 
circumstances  to  exclude  fraud,  unless  the  patient  be  previously 
well  known,  and  it  is  doubtful  whether,  if  genuine,  they  should 
not  be  regarded  as  instances  of  neurasthenia  acting  on  a  weak 
part,  rather  than  as  examples  of  hysteria  proper. 


TRAUMATIC   HYSTERIA.  215 

Re\T[ewing  all  these  cases,  together  with  other  numerous  pub- 
lished examples,  we  arrive  at  the  following  general  conclusions. 
The  most  common  symptom  is  anaesthesia.  This  is  usually  on 
the  left  side.  Of  eleven  of  my  cases,  in  seven  it  was  on  the  left, 
in  four  only  on  the  right.  The  anaesthesia  does  not  follow  the 
distribution  of  nerve-trunks,  but,  like  the  paralysis,  is  bounded 
by  straight  lines,  usually  either  dividing  the  limbs  into  segments, 
each  of  which  corresponds  to  a  joint,  or  more  often  marking  off  a 
whole  limb  from  the  body.  It  is  both  superficial  and  deep,  the 
muscular  sense  being  also  lost.  The  fauces  are  usually  anaes- 
thetic on  both  sides  (Charcot,  (^')  Dreschfeld  (*^)),  or  sometimes  on 
one  only  (Case  57). 

When  this  sensory  paralysis  takes  the  form  of  hemi-anaesthesib, 
(and  very  frequently  also  in  cases  in  which  it  is  limited  to  a  seg- 
ment only),  there  is  combined  with  it  aneesthesia  of  the  sensory 
organs  on  the  same  side — deafness,  loss  of  taste  and  smell,  and 
diminution  of  the  field  of  vision,  never  hemianopsia.  The  dimi- 
nution of  the  visual  field  may  affect  the  opposite  eye,  to  a  less 
extent  than  that  of  the  anaesthetic  side,  and  in  two  cases  I  have 
found  enlargement  of  the  field  in  the  opposite  eye.  The  dimi- 
nution is  usually  uniform  and  peripheral,  but  there .  may  be 
scotomata.  Achromatopsia  is  usually,  but  certainly  not  always, 
also  present. 

Hyperaesthesia,  superficial  or  deep,  is  usually  found  at  some 
part  of  the  body,  especially  in  the  neighbourhood  of  contracted 
joints.  It  is  frequently  found  also  at  parts  of  the  non-anaesthetic 
side  of  the  body.  The  relative  arrangement  of  ansesthesia  and 
hyperaesthesia  bears  no  resemblance  to  anything  seen  in  organic 
disease,  the  latter,  like  the  former,  being  bounded  by  straight  lines 
running  round  the  limbs.  Very  frequently  there  is  hyperaesthesia 
about  the  costal  margin,  in  the  groin,  or  in  the  testicle,  and  pressure 
on  such  a  hyperaesthetic  region  (hysterogenic  point)  may  induce 
a  hystero-epileptiform  crisis,  a  condition  which  does  not,  how- 
ever, appear  to  be  very  common  in  traumatic  hysteria. 

Par^esthesiae  are  various  and  inconstant  phenomena. 

Vaso-Motor,  Trophic,  and  Secretory  Symptoms. — These  are  much 
less  common  than  are  the  sensory  or  motor  phenomena  of  traumatic 
hysteria,  but  I  believe,  nevertheless,  that  we  do  meet  with  such 
symptoms,  due  to  hysteria,  and  to  hysteria  alone,  and  that  the 
following  cases  are  to  be  regarded  as  examples.  It  is  quite  usual 
to  find  the  regions  affected  with  hysterical  anaesthesia  very  pale, 
and  in  one  case  I  have  seen  marked  cedema.      Again,  although 


2l6  SURGERY    OF    THE    SPINAL    CORD. 

they  preserve  their  normal  electric  reactions,  the  paralysed 
muscles  often  undergo  a  good  deal  of  atrophy.  Hence,  there 
can  be  no  question  but  that  well-marked  vascular  changes  may 
result  from  hysteria,  and  if  so,  we  must  not  be  surprised  that  in 
some  instances  more  distinctly  trophic  and  secretory  symptoms 
ensue. 


Case  63. — Hysteria — Urticaria. 

A  married  woman,  aged  thirty-four,  was  injured  in  a  slight 
railway  collision,  receiving  a  blow  on  the  right  side  of  the  head, 
and  slight  bruises  on  the  left  arm  and  thigh.  For  a  short  time 
she  was  unconscious,  and  during  the  journey  home  she  said  she 
was  very  hysterical  all  the  way — the  term  is  her  own.  I  saw 
her  five  days  later,  when  her  chief  symptoms  were  an  excited 
manner,  a  quick  jerky  pulse,  palpitation,  and  premature  men- 
struation. But  about  a  week  after  the  accident  she  began  to  be 
troubled  with  a  rash,  of  the  nature  of  urticaria.  This  came  out 
every  evening  about  8  or  9  p.m.,  and  remained  until  1 1  a.m.  or 
noon  of  the  following  day.  It  consisted  of  large  bullae,  scattered 
all  over  the  body,  and  very  itchy,  followed  by  patches  of  redness. 
When  I  saw  her  on  the  afternoon  of  the  twentieth  day,  she  had 
numerous  red  raised  patches  over  the  lower  limbs,  due  to  these 
bullae.  Here  I  can  find  no  satisfactory  explanation  of  the  rash 
beyond  a  "  functional  "  vaso-motor  or  neuro-trophic  change.  The 
patient  was  certainly  taking  bromide  of  potassium,  but  this  had 
none  of  the  characters  of  a  bromide  rash.  It  continued  for  about 
three  weeks,  and  then  passed  off,  the  woman  recovering  entirely. 


Case  64. — Hysteria — Ancesthesia  and  hypermsthesia — Herpes. 

In  another  railway  case,  the  patient,  a  married  woman,  aged 
twenty-six,  received  bruises  of  the  left  leg,  right  side,  and  head. 
She  was  still  confined  to  bed  a  week  after  the  accident,  when  I 
saw  her,  and  she  then  complained  of  pain  about  the  second  lumbar 
vertebra.  Sensation  was  deficient  in  the  left  lower  limb,  exagger- 
ated in  the  right.  She  had  no  paralysis,  but  the  left  leg  "  seemed 
to  go  from  under  her  "  when  she  stood  up.  The  knee-jerks  were 
very  lively  on  both  sides,  the  plantar  reflex  more  marked  on  the 
right.  The  night  before  my  visit  she  had  a  "  fit,"  in  which 
severe  pain  in  the  head  was  followed  by  unconsciousness.  But 
the  most  interesting  point   is   that  she  had  developed   a  well- 


TRAUMATIC    HYSTERIA.  217 

marked  herpetic  eruption  on  the  right  side  of  the  body,  accurately 
limited  by  the  middle  line  before  and  behind,  and  occupying  the 
buttock,  groin,  and  upper  and  outer  part  of  the  thigh.  The 
region  thus  affected  was  very  painful,  and  in  the  right  groin  was 
an  inflamed  gland.  I  never  saw  the  patient  again,  but  am 
credibly  informed  that  two  months  later  she  was  well.  Here, 
then,  there  would  appear  to  have  been  no  organic  spinal  injury, 
but  merely  a  functional  change,  a  view  which  is  supported 
by  the  absence  of  paralysis,  of  bladder  or  rectal  troubles,  or  of 
marked  changes  in  the  reflexes,  by  the  co-existence  of  an  appa- 
rently hystero-epileptic  seizure,  and  by  the  rapid  recovery. 

In  the  following  case,  also,  I  think  that  we  must  look  to  a 
profound  functional  derangement  for  an  explanation  of  the 
symptoms. 


Case  65. — Sliock — Pyrexia. 

A  gentleman,  thirty-nine  years  of  age,  was  shaken  in  the 
Hexthorpe  railway  collision.  Five  days  afterwards  he  complained 
of  pain  in  his  "inside,"  back,  and  head,  and  of  startings  at 
night.  He  had  no  bruises,  nor  any  objective  signs  except  rather 
free  perspiration,  and,  although  intensely  nervous,  he  was  able  to 
be  out  of  bed.  On  the  eleventh  day  he  felt  much  more  unwell, 
and  was  very  restless  all  day ;  in  the  evening  the  temperature, 
which  had  previously  been  normal,  rose  to  102°  (pulse,  100). 
On  the  following  morning  the  temperature  was  lOi°,  pulse  lOO  ; 
he  could  scarcely  be  roused,  would  take  no  food,  and  passed  urine 
of  very  low  specific  gravity  (1005).  This  condition  continued 
for  two  days  more,  the  temperature  rising  to  101.4°,  and  he  was 
very  restless  and  slept  badly,  groaning  constantly,  and  refusing 
food.  He  also  became  almost  aphasic,  using  wrong  words,  and 
being  unable  to  fix  his  attention  upon  any  point,  or  even  to 
finish  his  sentences.  At  no  time  were  there  any  indications  of 
thoracic,  abdominal,  or  other  organic  mischief.  Then,  on  the 
evening  of  the  fourteenth  day  after  the  accident,  the  tempera- 
ture fell  to  99°,  on  the  following  morning  to  98°,  and  in  some 
two  days  more  he  was  as  well  as  before  the  attack.  A  perfect 
recovery  ensued,  and  six  or  eight  weeks  after  the  accident  he  was 
as  well  as  he  had  ever  been. 

In  this  same  category  of  hysterical  vaso-motor  troubles,  also, 
we  must  probably  place  a  not  very  infrequent  symptom — the 
passage  of  very  dilute  urine.      This  is,  I  am  inclined  to  think,  a 


2l8  SURGERY   OF    THE   SPINAL    CORD. 

distinctly  hysterical  manifestation.  It  is  very  common  in  ordi- 
nary traumatic  neurasthenia  to  find  the  urine  concentrated,  with 
a  deposit  of  urates,  but  the  reverse  condition  I  have  never  noticed 
without  other  hysterical  symptoms. 

Ovarian  hyperaesthesia,  again,  is  extremely  likely  to  be  due  to 
ovarian  hyperaemia,  and  a  general  hyperaomia  of  the  genital 
organs  (in  the  female,  at  any  rate)  would  explain  the  "  flood- 
ing" referred  to  in  Case  56,  as  well  as  premature  menstruation, 
which  is  frequently  observed  after  railway  accidents.  In  several 
of  the  above  cases  will  be  found  references  to  haematemesis 
and  melaena,  as  in  Case  53,  in  which  there  appears  to  have 
been  frequent  haematemesis  for  a  year.  Melaena  generally,  and 
haematemesis  often,  cannot  be  traced  to  fraud,  and  they  might 
also  be  explained  by  vaso-motor  changes.  I  would,  however, 
wish  it  to  be  clearly  understood  that  on  these  vaso-motor  symp- 
toms I  now  speak  with  great  reserve.  The  facts  of  the  above 
cases  are  correctly  recorded,  the  explanation  is  most  obscure. 


5.  Pathology. 

The  classical  researches  of  Charcot  have  established  beyond 
question  the  practical  identity  of  the  symptoms  of  traumatic 
hysteria  with  those  which  can  be  produced  by  suggestion  during 
the  hypnotic  sleep.  In  patients  hypnotised,  not  too  deeply,  it 
is  possible  to  produce,  either  by  manipulation  of  the  limbs,  or 
by  authoritative  assertions  to  the  subject  of  experiment,  paralysis 
and  anaesthesia  absolutely  similar  in  character  to  those  which 
have  been  described  above.  Hence  we  are  naturally  led  to  seek 
for  an  explanation  of  the  traumatic  results  by  a  comparison  with 
the  fairly  well  explained  manifestations  of  the  hypnotised.  For 
this  purpose  we  require  the  analogues  of  the  hypnotic  state  and 
of  the  suggestion. 

As  regards  the  latter,  Charcot  has  shown  that  in  hypnotised 
persons,  light  blows  may  often  produce  paralysis  and  anaesthesia, 
apart  from  verbal  description  to  the  subject  of  the  results  which 
are  to  ensue.  Hence  he  postulates  the  theory  of  auto-snggcstion. 
A  blow  causes  a  sense  of  congestion  or  weight  in  the  implicated 
region,  and  this  would  appear  to  be  capable  of  inducing  the  idea 
of  paralysis,  which  is  forthwith  translated  by  a  disordered  cortex 
into  the  fact.  It  is  clear,  then,  that  in  the  hypnotic  condition  a 
slight  trauma  is  capable  of  evoking  by  auto-suggestion  mani- 
festations identical  with  those  of  hysteria.     But  further,  Charcot 


TRAUMATIC    HYSTERIA.  219 

has  found  that  in  one  case,  at  any  rate,  previous  hypnotism  was 
not  essential  to  the  production  of  this  result,  and  hence  he  is  led 
to  believe  that  conditions  other  than  those  produced  by  the 
ordinary  methods  of  hypnotism  may  predispose  an  individual  to 
these  hysterical  manifestations.  Such  a  condition  he  believes  to 
be  supplied  by  "  nervous  shock,"  and  he  thus  arrives  at  the  con- 
clusion that  the  two  elements  necessary  for  the  connection  of 
traumatic  with  hypnotic  hysteria  are  provided.  ' '  Nervous  shock  " 
replaces  hypnotism,  "  auto-suggestion  " — a  result  of  abnormal  sen- 
sations provoked  by  the  injury — replaces  suggestion  by  the  ope- 
rator. This  theory  has,  like  most  other  theories,  been  attacked, 
but  it  certainly  appears  better  suited  than  any  other  yet  advanced 
to  explain  the  facts  which  present  themselves. 

In  an  early  portion  of  this  paper  I  have  referred,  under  the 
name  of  "  acute  hysteria,"  to  certain  common  conditions  result- 
ing from  nervous  shock,  which  correspond  very  closely  indeed  to 
those  of  the  slighter  degrees  of  hypnotism.  The  peculiar  inatten- 
tive condition  there  described,  accompanied  as  it  is  by  disordered 
imaginations,  thus  presents  one  factor  in  our  pathological  nexus, 
and  we  may  regard  the  inhibition  of  cerebral  action,  thus  evoked 
by  the  shock  of  an  accident,  as  being  very  closely  allied  to  that 
produced  by  the  efforts  of  the  mesmeriser. 

The  suggestive  element  is  even  more  easy  of  explanation. 
In  most  cases  of  traumatic  hysteria  we  find  that  the  paralysed 
region  bears  a  close  relation  to  the  region  injured,  and  here  the 
subjective  effects  of  a  blow  sufiice  to  explain  the  origin  of  the 
idea  of  paralysis.  Every  one  must  be  familiar  with  the  numb, 
dead  sensation  following  a  blow,  especially  a  blow  upon  a  nerve- 
trunk  ;  and  can  anything  be  more  likely  to  suggest  the  idea  of 
paralysis  ?  The  suggestion  naturally  becomes  most  pressing  in 
such  instances  as  Case  62,  in  which  a  local  organic  paralysis 
and  anaesthesia  are  already  vividly  presenting  themselves  to  the 
patient's  consciousness.  Then,  again,  it  must  be  remembered 
that,  in  the  case  of  railway  accidents  at  any  rate,  the  general 
public  of  this  country  has  been  educated  to  expect  "concussion 
of  the  spine  "  with  paralysis,  and  that,  in  the  minds  of  the  laity, 
the  very  mention  of  a  railway  accident  calls  up  the  required 
idea.  Other  elements  may  also  be  present,  as,  for  instance, 
powerful  emotions,  which,  especially  in  the  case  of  fear,  fre- 
quently cause  a  passing  inhibition  of  muscular  force,  manifested 
by  staggering,  trembling,  or  even  falling,  and  which  are  obviously 
supplied  by  the  accident.  Thus  there  are  various  obvious  channels 
by  which  the  idea  of  paralysis  may  readily  be  suggested. 


2  20  SURGERY    OF   THE   SPINAL   CORD. 

On.  these  grounds,  then,  there  appears  to  be  the  closest  pos- 
sible connection  between  traumatic  hysteria  and  the  paralysis 
of  hypnotic  suggestion,  and  on  these  grounds  we  must,  I  think, 
accept  the  theory  of  Charcot. 

If  we  attempt  to  go  further,  and  to  inquire  into  the  material 
basis  of  hysteria,  we  find  ourselves  almost  hopelessly  without  the 
guidance  of  facts,  and  we  pass,  moreover,  to  the  consideration  of 
questions,  which,  as  they  relate  to  all  varieties  of  hysteria,  and 
by  no  means  to  the  traumatic  form  only,  I  do  not  intend  now 
to  discuss.  Suffice  it  to  say  that  the  change  is  almost  certainly 
cortical,  and  is  probably  associated  with  an  anaemia  of  one  side 
of  the  cortex,  possibly  with  a  correlated  hypereemia  of  the  other. 

6.  Prognosis. 

My  own  experience,  relating,  as  it  does,  mainly  to  isolated 
examinations,  hardly  furnishes,  if  taken  alone,  sufficient  grounds 
for  any  definite  conclusions  on  this  most  difficult  of  questions ; 
nor  do  we  find  in  current  literature  any  very  satisfactory  data ; 
but  a  comparison  of  experience  with  previous  observations  is  not 
altogether  without  value.  Whereas  some  writers  refer  to  these 
cases  as  practically  incurable,  others  speak  of  them  as  almost 
invariably  recovering  with  rapidity,  and  on  both  sides  we  find 
opinions  expressed  with  a  perhaps  somewhat  unwarrantable  dog- 
matism. The  main  reason  of  this  discrepancy  would  appear  to 
be  that  the  question  of  pecuniary  compensation  enters  in  a 
varying  degree  into  relationship  with  the  cases  observed  by 
different  authors.  Before  we  can  arrive  at  any  definite  decision, 
we  must  endeavour  to  divest  ourselves  of  this  source  of  confusion. 
Looking  to  our  otvti  cases,  we  find  three  only  in  which  there  was 
no  such  question  (Cases  53,  54,  and  57).  These  were  all  treated 
in  hospital,  and  had  all  been  previously  neglected.  Before  they 
came  into  hospital  they  either  manifested  no  tendency  to  im- 
provement, or  were  getting  distinctly  worse.  In  hospital,  on 
the  other  hand,  the  improvement  was  rapid  and  obvious.  Un- 
fortunately, the  exigencies  of  public  practice  do  not  allow  of 
their  being  retained  sufficiently  long  for  the  completion  of  a  cure, 
but  we  can  hardly  doubt  that  a  more  prolonged  stay  would  suffice 
to  produce  this  result,  and  these  cases  seem  strongly  to  suggest 
the  probability  of  a  complete  cure  within,  at  most,  a  few  months, 
provided  the  conditions  he  satisfactory. 

Most  instructive  in  this  connection  are  the  following  cases 
recorded  by  Mr.  Collier  ('*').      Briefly,  these  are  as  follows  : — 


TRAUMATIC    HYSTERIA.  22  1 

(i.)  Fall  on  head.  Epileptiform  seizures;  almost  complete 
aneesthesia ;  retraction  of  field  of  vision ;  retention  of  urine. 
Recovery  in  three  days. 

(2.)  Crush  of  toe.  Ansesthesia  of  limb.  Recovery  in  one 
month. 

(3.)  Fall  on  shoulder.  Contracture  of  limb;  retraction  of 
field  of  vision.  Date  of  recovery  not  known,  but  patient  ceased 
to  apply  for  treatment  after  a  fortnight. 

(4.)  Fall.  Mutism ;  paralysis  of  adductors  of  vocal  cords ; 
paralysis  of  tongue  ;  convulsions.  Immediate  recovery  on  faradisa- 
tion ;  return  of  symptoms  in  a  few  hours ;  permanent  recoveiy 
on  a  second  faradisation. 

In  none  of  these  was  there  any  question  of  compensation,  and 
all  were  properly  treated  from  the  first. 

If,  then,  there  be  no  pecuniary  complication,  and  if  the  case 
be  at  once  placed  under  proper  treatment,  we  may  apparently 
expect  perfect  recovery  within  a  few  weeks.  If,  again,  the  case 
be  neglected,  but  the  financial  diflSculty  be  still  excluded,  the 
symptoms  appear  to  become  more  fixed,  and  a  longer  period, 
probably  some  months,  may  be  required  for  an  absolute  cure. 
That  in  either  case  an  absolute  cure  is  to  be  expected  appears  to 
me  almost  certain,  both  from  the  above-quoted  and  from  other 
published  cases.  I  am  confirmed  in  this  opinion  by  the  fact  that, 
whereas  traumatic  hysteria  is  by  no  means  rare,  I  am  unac- 
quainted with  old  standing  incurable  cases  such  as  we  should 
meet  if  the  symptoms  were  persistent,  and  at  the  same  time  (as 
is  universally  admitted)  very  rarely  fatal. 

Unfortunately  the  majority  of  these  cases  arise  from  railway 
injuries,  and  here  we  always  have  the  baneful  effects  of  the  com- 
pensation question.  Now  it  must  be  admitted  that  these  cases 
do  not  recover  so  rapidly  as  those  to  which  we  have  already 
referred,  and  we  are  led  to  ask  why  this  should  be  so  ?  Is  it 
because  the  results  of  railway  collisions  are  much  more  severe, 
or  because  the  expectation  of  compensation  increases  the  dura- 
tion of  the  symptoms  ?  Connected  as  I  have  been  with  several 
railway  companies,  I  have  been  struck  by  two  facts,  viz.,  first, 
that  among  the  large  number  of  railway  oflicials  of  every  social 
grade  whom  I  have  known,  many  of  whom  have  been  passengers 
at  the  time  of  collisions,  but  none  of  whom  can  claim  compensa- 
tion, I  have  never  met  with  any  who  have  suffered  from  severe  or 
persistent  nervous  symptoms ;  and  second,  that  in  none  of  the 
accidents  with  which  I  have  been  concerned  has  any  railway  ser- 
vant complained  of  such  symptoms.     Bruises,  fractures,  bums. 


222  SUEGERY    OF   THE    SPINAL    CORD. 

and  deaths  we  meet  with  only  too  frequently,  but  traumatic 
hysteria  is  to  me  unknown  in  either  of  these  two  classes  of 
persons.  As  railway  officials  are  similarly  constituted  to  the  rest 
of  the  population,  I  presume  that  they  do  occasionally  suffer  from 
traumatic  hysteria,  and  I  can  therefore  only  conclude  that  they 
recover  from  it  within  a  brief  period. 

We  are  thus,  then,  driven  to  the  view  that  compensation,  or 
rather  waiting  for  compensation,  markedly  aggravates  the  hysteri- 
cal symptoms,  a  position  which  we  can  assume  without  for  one 
moment  impugning  the  honesty  of  all  the  sufferers  with  whom 
we  meet.  Q.''he  origin  of  traumatic  hysteria  being  an  idea  or  a 
suggestion,  it  is  but  natural  that  anything  which  tends  to  fix 
this  idea  will  operate  towards  retarding  convalescence.  In  a 
compensation  case  everything  does  tend  to  fix  the  idea.  The 
repeated  examinations  by  various  experts,  the  frequency  with 
which  the  patient  is  called  upon  to  detail  his  every  symptom  and 
sensation,  the  accounts  of  his  accident  which  he  reads  in  the 
press,  the  almost  continuous  repetition  to  himself  of  his  sufferings, 
all  serve  but  too  well  to  rivet  the  suggestion  on  a  mind  weakened 
by  the  worry  of  legal  proceedings  and  by  the  fear  of  the  popu- 
larly accepted  fate  of  the  victim  of  "  railway  spine."  And  thus 
we  find  that,  in  these  "compensation  cases,"  the  prognosis  of 
traumatic  hysteria  becomes  much  more  grave  than  in  those  to 
which  we  have  already  referred. 

It  may  be  objected  that  if  the  waiting  for  compensation  be 
the  cause  of  this  additional  prolongation  of  the  illness,  payment 
should  induce  a  recovery  as  rapid  as  in  other  cases,  but  a 
moment's  consideration  will  show  that  this  is  not  so.  We  have 
already  seen  how  mere  neglect  or  unsuitable  treatment  renders 
an  ordinary  case  much  more  intractable,  even  when  it  does  at 
last  acquire  more  satisfactory  surroundings,  simply  because  the 
longer  the  symptoms  have  lasted  the  more  rooted  has  become  the 
idea,  and  the  longer  it  is  likely  to  last.  Hence  we  must  not 
expect,  as  a  rule,  to  find  an  immediate  entire  recovery  after 
settlement  of  a  claim,  but  we  are  certainly  justified  in  saying 
that  recovery  will  thereby  be  rendered  comparatively  very  rapid. 
All  of  the  cases  above  quoted,  in  which  the  subsequent  history  of 
the  patient  has  been  traced,  bear  out  this  view.  And  it  would 
seem  not  improbable  that  the  rate  of  recovery  after  compensation 
may  bear  a  direct  ratio  to  the  duration  of  the  symptoms  before 
it.  Thus,  in  Case  52,  the  settlement  was  made  within  a  fortnight 
of  the  accident  (before  I  saw  the  patient),  and  within  a  month 
the  improvement  was  so  great  that  very  little  inconvenience  was 


TRAUMATIC    HYSTERIA.  223 

caused  by  the  symptoms.  In  Case  56,  in  which  no  compensation 
could  be  claimed,  recovery  ensued  in  a  few  weeks ;  and  we  may 
note,  in  passing,  that,  among  the  injured  in  the  collision  which 
produced  this  case,  there  were  no  other  instances  of  traumatic 
hysteria.  Case  58  showed  little,  if  any,  improvement  during  the 
seven  months  before  settlement,  but  one  month  after  it  the 
patient's  medical  adviser  (whose  services  had  already  ceased  to  be 
required)  writes  : — "  I  was  surprised  to  see  him  looking  so  well. 
In  appearance  he  has  certainly  improved  very  much."  The 
patient  himself  still  complained  of  some  disability,  but,  in  the 
absence  of  details,  we  may  take  the  above  as  a  satisfactory 
report.  Case  60  was  that  of  a  man  who  was  able  within  a 
month  of  the  accident  to  pursue  his  occupation  of  a  book- 
maker. Cases  50  and  62  were  only  settled  many  months  after 
the  accident,  and  at  the  end  of  a  year  there  was  still  slight 
antesthesia  in  both,  but  in  neither  case  did  such  symptoms  as 
persisted  interfere  materially  with  the  comfort  of  the  patient. 
In  Case  6 1  the  hysterical  symptoms  shortly  disappeared,  but  the 
neurasthenic  troubles  persisted  for  a  year,  and  then  yielded  in  a 
few  weeks  to  the  effects  of  pecuniary  compensation. 

In  order  to  give  the  more  accurate  prognosis,  it  is  necessary  to 
consider  certain  other  conditions  which  will  influence  the  duration 
of  traumatic  hysteria.  Thus,  in  the  male,  the  symptoms,  although 
less  readily  produced,  appear  to  be  more  fixed  in  character  than 
in  the  female  (Charcot).  A  neurotic  tendency,  whether  heredi- 
tary or  acquired,  is  also  of  bad  omen.  Chronic  alcoholism,  again, 
tends  to  render  the  prognosis  worse.  Marked  fluctuation  in  the 
sjinptoms,  such  as  transference  of  hemi-ana3sthesia  from  one  side 
of  the  body  to  the  other,  or  temporary  disappearance,  as  in  Case 
59,  are  eminently  favourable  conditions.  The  case  last  referred 
to  illustrates  very  distinctly  the  disastrous  effect  of  legal  pro- 
ceedings in  aggravating  the  hysterical  troubles. 

In  the  above  remarks  a  possible,  although  a  rare  eventuality, 
has  been  ignored.  Life  is  but  seldom  imperilled  by  traumatic 
hysteria,  but  that  complications  may  ensue  which  may  terminate 
in  death  is  shown  by  the  following  remarkable  case. 


Case  66. — Hysterical  hemi-ancesthesia  and  retention  of  wine — 
Vomiting — Cystitis — Exhaustion — Death. 

An  unmarried  girl,  twenty-four  years  of  age,  was  injured  in  a 
slight  railway  collision.      She  became  unconscious,  and  did  not 


2  24  SURGERY    OF    THE   SPIXAL   CORD. 

remember  the  circumstances  of  the  accident.  -.  i^hen- 1-  saw- her 
on  the  following  day,  she  complained  of  pains  all  over  her  body, 
but  especially  in  the  head,  left  side,  and  back.  She  tossed  about 
very  restlessly  in  bed,  but  said  that  all  movements  caused  pain. 
The  pulse  was  quick  (io8),  and  she  had  marked  "  facies  hysterica," 
but  there  were  no  other  signs  of  injury.  I  did  not  examine  the 
sensation. 

I  saw  her  again  a  fortnight  later,  and  found  her  in  a  very 
quiet — it  might  almost  be  said  semi-comatose — condition,  from 
which  she  had  to  be  roused  before  she  would  pay  any  attention 
to  questions.  In  spite  of  this,  she  started  violently  on  hearing 
the  slightest  sudden  noise.  I  was  told  that  she  was  often  quite 
unconscious  for  hours  at  a  time.  She  had  anaesthesia  of  the 
right  side  of  her  face  and  chest  and  of  the  right  hand,  but  for 
several  reasons  I  made  no  further  examination  of  her  sensation. 
.jPwas  also  told  that  ever  since  the  accident  she  had  had  to  have 
her  urine  withdrawn  by  the  catheter,  and  that  she  vomited  con- 
stantly. The  bowels  were  much  constipated,  and  could  be  re- 
lieved only  by  enemata.  Shortly  before  this  she  had  been  seen 
by  Dr.  Ross,  who  did  not  then  regard  the  case  as  a  very  serious 
one — an  opinion  which  I  certainly  shared. 

She  now  appears  to  have  become  rapidly  worse,  and  a  week  or 
so  later  was  seen  by  Dr.  Dreschfeld,  who  then  found  her  comatose, 
with  universal  anaesthesia,  fever,  and  cystitis.  I  know  little  of 
the  termination  of  the  case,  except  that  some  weeks  after  the 
accident  she  died  exhausted: 

There  was  no  post-mortem  examination,  but,  in  the  absence 
of  any  evidence  whatever  of  a  gross  lesion — a  point  upon  which 
all  who  saw  her  were  agreed — it  would  appear  that  this  was  a 
case  of  death  from  exhaustion,' due  to  hysteria,  with  persistent 
vomiting,  and  cystitis  from  retention  of  urine. 

Such  a  termination  must  be  extremely  rare,  but  its  possibility 
has  to  be  considered  in  giving  a  prognosis. 

7.  Treatment. 

\  Goncerning  treatment,  I  have  nothing  to  add  to  the  results  of 
pjpe\aous  observers.  On  one  point,  however,  I  would  strongly 
insist — the  advisability  of  separation  from  friends  and  relatives. 
The  value  of  rsuch.  isolation  in  various  other  neuroses  is  generally 
admitted.  ,  Weir  Mitchell  and  Playfair  have  demonstrated  the 
benefit  to  be  derived  from  it  in  the  case  of  hysteria,  and  the 
above-quoted  hospital  cases  but  confirm  their  conclusions.    Adopt- 


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04/13/95       10:49 


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